HCA, Hospital Corporation of America Division Director of Denial Prevention in Irving, Texas

_Division Director of Denial Prevention_ _Medical City Healthcare Division Office_

The Division Director of Denial Prevention provides data analysis, process direction, and oversight of all levels of effective denial appeal and prevention for the division. Maintaining a current level of federal and state statue, as well as contractual language will be a necessary function of the position, as well as fostering communication of that knowledge to all facilities, departments within those facilities, and patient accounting departments which are included in the area of responsibility. The division director works closely with the patient accounting service centers and facilities to assist with identification of denial root cause analysis and formulation of processes that lead to significant improvement.

The division director works cooperatively with the corporate regulatory department in the assessment and formulation of benchmark denial prevention strategy and fosters effective communications and implementation of best practices at all facilities and accounting services. Also, to provide insight in to national and local coverage determinations this may be questionable or unreasonable in the application in the clinical setting.

In addition to the implementation of successful appeal efforts, the analysis of denials will provide a guide for methodical and strategic process improvement to initiate process enhancement aimed at the prevention/avoidance of each subsequent denial.

Education centering on incidence and process improvement will be performed as warranted by immediacy, but will also be scheduled on a monthly basis to maintain communication on current practices to maintain open communication and need for subsequent action.

The division director will work closely with division provider relations to foster meetings with payer groups for the purpose of process clarification, process improvement, and conflict resolution.

At all levels of the company and between all disciplines, the division director champions HCA strategy and company/division/facility initiatives to ensure short term and long term objectives are operationalized within assigned facilities. The Division Director will provide engaged leadership to facility Executive Staff and in regards to the minimization of financial risk related to denials. The Division Director is a subject matter expert and serves as an internal consultant to multiple facilities and departments within the company. The Division Director identifies improvement opportunities and facilitates process standardization to promote improved outcomes, maximize resource utilization, and improve organizational efficiencies. This position is required to travel to and from locations within assigned geographic area.

• Provides leadership to and actively participates with facility staff to identify, implement, or enhance denial prevention programs consistent with HCA and division strategy. • Assesses all components and performance of facility departments that may demonstrate financial risk in identified facilities • Disseminates information accurately and timely with multiple audiences; leads regularly scheduled communication sessions with various departments in facilities and patient accounting centers. • Identifies process improvement opportunities; develops, implements, monitors and revises action plans • Identifies and shares best demonstrated practices; stays abreast of current practice standards, shares within division and across company, facilitates standardization where appropriate • Recommends and reviews policy and procedure; assists with the development, revision and implementation of Denial Management policy and procedure, and implements HCA policy and procedure. • Facilitates the implementation of regulatory requirements, HCA Ethics and Compliance policies, and quality initiatives related to Denial Prevention services; provides regulatory and compliance updates, provides standards of practice updates, initiate and drives process changes to ensure compliance to such regulations and quality initiatives as it relates to the provision of Denial Management Services; validates data integrity of required and approved regulatory reporting. • Fosters communication and facilitates collaboration between the facilities and PAS, and other departments within HCA. • Data analysis related to Denial Management metrics; develops implements and monitors action plans related to denials. • Performs random denial audits to validate policy, procedure and standards are met; works with facility Director to develop action plans, works with Denial Management team, Case Management, Patient Access Department, and Regulatory Compliance teams prior to developing and implementing facility or division wide audits. • Designs, implements and monitors processes to ensure facility outcomes are achieved related to managed care contracts; appropriate authorizations or determinations of medical necessity for all payers sources are obtained and documented, facilitates collaboration with hospital staff, PAS, managed care with a goal of contract compliance and decreasing payer denials or non-medically necessary days at the facility level • Ensures that standards of optimal denial management practice and integrated services are developed, implemented and monitored that are consistent with professional standards and regulatory requirements; researches resources to resolve issues based on evidence or current practice • Anticipates and proposes opportunities to improve current technology or identify new technology to enhance performance and productivity: Leads initiatives in assigned facilities. • Assesses learning needs related to appeal formulation and practice, and implements appropriate educational activities to expand knowledge base

_Qualifications_ _ _ * Five years as a leader with hospital financial experience or clinical operations including claims denials. * BA required * Knowledge of Case Management * Knowledge of utilization review Texas statue * Knowledge of federal plan administration, including National and Local Coverage Determination * Ability to establish and maintain collaborative and effective working relationships with various facilities and multiple departments within those facilities, with patient accounting services, and with division and corporate level departments. * Ability to communicate effectively in oral, written and electronic formats * Ability to demonstrate analytical and critical thinking abilities with pro-active decision-making, problem solving and negotiation skills

Job: *Directors & Managers

Title: Division Director of Denial Prevention

Location: Texas-Irving-North Texas Division Office

Requisition ID: 26500-100798