Responsible for partnering with clients to improve financial and operational performance, transfer knowledge and resources, and sustain improvements over time. Coach and mentor client OP CDI, clinical ancillary staff, and Revenue Integrity staff through shadowing and education. Write policies and procedures for the charge audit department. Review appeals and facilitate negotiations with providers.

Manage and provide direct supervision of a large team of nurses and coders for a large hospital system with different EMRs, policies, payer contracts, and reporting requirements. Manage projects including, but not limited to, external client implementations, development of additional clinical service offerings, and refinement of existing clinical service offerings to deliver exceptional value and service to clients. Provide performance management, including coaching as the need arises; ensure engagement of clinicians. Collaborate with other departments, both internal and external, to ensure the delivery of quality service. Monitor productivity and daily inventory to prevent backlog and implement various worklist strategies—knowledge of managed care contracts, including reimbursement matrixes, terms, and authorization guidelines. Develop and update clinical denial policies and procedures. Provide direct supervision of nursing staff and serve as a daily resource, responding to questions encompassing all aspects of the CRC processes/procedures and assisting with defining unclear dispute types. Manage accesses for new client engagements and provide training on how to navigate systems, hospital processes, and scope of practice. Serve as a daily resource assisting with defining unclear dispute types. Assists in the development of new and innovative strategies and services.

Key collaborator of the new Quality Audit Program for a staff of 56 nurses on the clinical audit team. Creation of audit tool and QA process for the monthly quality reviews with the director of the team. Manage and provide direct supervision to two QA Nurse Educators, each managing up to 27 nurses’ quality and productivity. Provide instruction and education regarding a compelling appeal for those disputes as needed. Monthly reporting analysis of each nurse's productivity, appeals, and other status code reviews. Support quality educators during monthly quality audit meetings.

Manage and provide direct supervision of a team of up to 6-7 appeals nurses for a large hospital system with different EMRs, policies, client contacts, payer contracts, and reporting requests. Knowledge of managed care contracts, including reimbursement matrixes, terms, and authorization guidelines. Develop and update clinical denial policies and procedures as applicable. Ability to prioritize meetings, tasks, and urgent business needs. Assists in the development of new and innovative strategies and services. Serve as a daily resource responding to questions encompassing all aspects of the CRC processes and procedures. Collaborate with other departments to ensure the delivery of quality service. Monitor productivity and daily inventory to prevent backlog and implement various worklist strategies. Provide direct supervision of nursing staff. Conduct research regarding related regulatory processes/guidelines to ensure compliance with processes related to Conifer and business unit objectives.

Recovery of revenue of disputed/denied clinical claims. Prepare and document appeal-based industry-accepted criteria. Knowledge of managed care contracts, including reimbursement matrixes and terms. Research State/Federal appellate guidelines and applicable regulatory processes related to the appellate process. Conduct research regarding the off-label use of medication and any experimental/ investigational implants, medications, and/or procedures. Assess the need for formal appeals of all clinical denials. Appeal rejections per the appeals process for the provider contracts. Audit clinical documentation to ensure its sufficiency.