Medicare Authorization & Denials Manager

ClearSky hospitals provide high-quality care that transforms the lives of those living with disabling injuries and illnesses. We distinguish ourselves through our commitment to excellence, to our patients, to our employees, and to the communities we serve.

We are currently looking for a Medicare Authorization & Denials Manager to join our growing team! The right person will hold active nursing licensure and have in depth experience in synthesizing clinical documentation for each patient’s stay into justification for services that meets Medicare regulations. Experience and/or in-depth knowledge and understanding of Review Choice Demonstration regulations is strongly preferred. This position is remote and will oversee our Texas locations.

The Medicare Authorization & Denials Manager will be responsible for obtaining Medicare authorization and approval for patients that have been admitted to a ClearSky Hospital. Includes synthesizing clinical documentation for each patient’s stay into justification for services that meets Medicare regulations. Approval includes initial approval as part of the Review Choice Demonstrations and overseeing denials through the appeal process. This position is remote.

Essential Functions

• Develop and lead the optimal process to obtain Medicare approvals through the Review Choice Demonstration.
• Keep current on changes in the Review Choice Demonstration including different approaches for each MAC and results from other reviews. Modify our processes as needed based on any new information.
• Work with the Hospitals to prepare all required information and justification to submit for the Medicare authorization. Reviews clinical data on admissions and help ensure information complies with Medicare regulations.
• Discusses justification for admission and denial reasons with the Medicare Contractor. Work with hospitals on documentation issues with denied admissions.
• Pursues appeals for denials of admission to rehabilitation program in an expeditious and thorough manner.
• Provides on-going guidance and collaboration with the Hospital teams and physicians on appropriate required Medicare documentation based on feedback from the Medicare contractor.
• Maintain organized tracking system to ensure deadlines are not missed and real time information on new admissions, approvals, and denial status. Must ensure timeliness of required submissions.
• Collaborates and communicates with the ClearSky Hospital Admissions team which includes timely and accurate notification of new admissions.
  
  

Minimum Job Requirements

Minimum Education and Experience

• Three (3) years' experience with Medicare regulations in an Inpatient Rehabilitation Facility (IRF) strongly preferred.
• Experience with identification, analysis, and research of pre- and post-service denials (to include Medicare) to identify discrepancies, errors, etc. strongly preferred.
• Patient Chart Auditing in Electronic Medical Records (EMR) required.
  
  

Required Licenses, Certification, and/or Documentation

• Active RN or LPN/LVN
  
  

Required Knowledge, Skills, And Abilities

• Knowledge of clinical operations and procedures, including complex patient conditions
• Demonstrates understanding of insurance authorization and denial processes
• Experience interacting with Medicare Contractors
• Effective written and verbal communication skills
• Demonstrates the highest degree of customer service and professionalism
• Effective organizational and time management skills
• Ability to work independently
• Ability to maintain proper levels of confidentiality
• Ability to work closely and professionally with others at all levels of the organization
  
  

ClearSky is proud to be an equal opportunity employer. We also offer competitive pay and benefits to include student loan repayment assistance, tuition reimbursement, 401K and HSA match. Apply today and make a difference in the lives of our patients! #INDALB