The Supervisor, Clinical Denials & Claims Resolution, is responsible for overseeing the essential functions of the claims resolution and denials team to ensure timely and accurate resolution of claims and denials. This position requires strong collaboration with healthcare providers, contracted payer representatives, and Patient Financial Services (PFS) Supervisors to mitigate payment delays and optimize revenue cycle performance. The Supervisor will stay updated on insurance industry regulations, policies, and procedures to effectively navigate claim resolution processes.  Additionally, they will assist the Director of Patient financial Services in overseeing all patient financial functions and serve as a liaison between various departments within Memorial Health System.  Implementing strategies and tactics that enhance operational efficiency, and departmental effectiveness will be a high priority.

 

Job Functions:

Lead the review, resolution, and prevention of clinical claim denials by applying clinical expertise to ensure accurate and timely reimbursement. Develop and implement action plans to improve net revenue performance, enhance Accounts Receivable (AR) turnover, reduce AR aging, and optimize First Pass Denial Resolution Rate. Utilize clinical knowledge to assess denial trends, collaborate with healthcare providers, and implement strategies that address root causes of denials while ensuring compliance with payer policies and regulatory requirements. Establish and monitor annual departmental goals focused on staff engagement and effective clinical denial management, ensuring team members understand performance expectations and their role in revenue cycle success. Provide weekly updates on key performance indicators related to denial resolution, reimbursement trends, and revenue cycle efficiency. Work closely with the Director to evaluate and refine workflows that improve claims resolution, appeal processes, and overall financial performance. Utilize clinical expertise to support accurate claim documentation and coding practices. Regularly review patient accounting systems and claims data for opportunities to improve performance and efficiency. Collaborate with IT to address system limitations, recommend enhancements, and ensure alignment with revenue cycle and clinical documentation improvement initiatives. Develop and implement strategies for recruitment, retention, and professional development of staff, ensuring a diverse and highly skilled workforce with expertise in clinical denial management. Standardize work processes to ensure staff productivity, maintain quality benchmarks, and minimize staffing variances from budget. Ensure clinical documentation aligns with billing and reimbursement guidelines. Apply evidence-based practices in policy development, staff education, and workflow optimization to enhance claims resolution and appeals effectiveness. Serve as a key liaison between the Clinical Denials & Claims Resolution team, clinical departments, and revenue cycle teams to bridge the gap between clinical care and financial processes. Promote a patient-centered approach by ensuring claims resolution processes align with high-quality patient care, clear communication, and efficient billing practices. Establish and monitor key performance indicators (KPIs) to drive continuous improvement in clinical denial resolution, reimbursement accuracy, and financial outcomes. Collaborate with Health Information Management (HIM) and Patient Access leadership to develop competency-based training, ensuring staff are equipped with both clinical and revenue cycle knowledge. Conduct mid-year and annual employee performance evaluations based on direct observation, measurable outcomes, and adherence to best practices in clinical denial management. Participate in hiring, onboarding, supervising, developing, evaluating, and retaining staff, ensuring alignment with both clinical and financial goals. Maintain compliance with hospital policies, accreditation standards, and payer regulations by overseeing staff training, documentation practices, and adherence to guidelines. Exercise independent judgment in personnel decisions, including hiring, performance management, and disciplinary actions, while ensuring alignment with clinical and revenue cycle priorities. Maintain accountability for all supervisory duties, ensuring staff performance meets organizational standards and aligns with the hospital’s mission of quality patient care and financial stewardship. Assumes all other duties and responsibilities, as necessary.