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What you be doing in this role:
Under the supervision of the Executive Director, the Manager is responsible for overall management and communication of all government audits and of clinically based denial management appeals between Cedars-Sinai and commercial outside payers. The Manager will also oversee CSMC compliance with government regulations relating to patient status. He or she will act as a liaison and point of contact for all government contracted agencies, division and other internal representatives for denial and appeal inquiries. The Manager will actively manage, maintain and communicate to appropriate business partners denial and appeal activities, trends, and recommended corrective action plans. Manager will also work with team and other CSMC departments to develop data and reports that show critical metrics for the department. Manager will also actively participate as a member of the Government Audit Program (GAP). Supports research, participates in strategic planning, both long and short term, and assures patient advocacy.
Supervises unit employees. This includes responsibility for determining qualifications, hiring, terminations, performance management, salary, assigning work, maintaining and improving competence, coaching, training, orientation, in-service and continuing education.
Manages review of short stay Medicare inpatients for compliance with CMS regulations
Performs case management review of issues related to compliance with government payer coverage issues as well as commercial denials
Identification and facilitation of educational opportunities with other departments, providers, and payers to decrease denials and improve quality of service to patients. Conduct informal and formal education programs within the organization
Utilizes electronic database to track reason for denial, result of denial review as it relates to ability to appeal, date of appeal actions, outcome of appeal if appropriate
Works in collaboration with other departments and health plans to develop corrective action plans to address identified trends in reasons for denials
Provides oversight of the patient classification programs including but not limited to the pre-procedure review program and the Executive Health Resources vendor, and engagement
Providing healthcare for more than 100 years, Cedars-Sinai has evolved into one of the most dynamic and highly renowned medical centers in the world. Along with caring for patients, Cedars-Sinai is a hub for biomedical research and a training center for future physicians and other healthcare professionals. This attracts exceptional talent to Cedars-Sinai, including world-renowned physician-scientists who seek a place where they can both conduct research and see patients--the ideal formula for discovery and its translation into cures. Our patients benefit from access to doctors at the top of their fields, and our researchers have an ideal community in which to study the impact of healthcare challenges, and reflect that knowledge in their research. The greater Los Angeles area in which Cedars-Sinai resides possesses unparalleled cultural and ethnic diversity which offers outstanding opportunities for translational and clinical research and a dynamic environment for medical education.Although community based, Cedars-Sinai is a major t...eaching hospital affiliated with the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). Cedars-Sinai has highly competitive graduate medical education programs in more than 50 specialty and subspecialty areas, a graduate program in biomedical sciences and translational medicine, a clinical scholars program directed towards junior physicians with aspirations to become clinical scientists, and post graduate training opportunities.There are more than 250 full-time faculty members at Cedars-Sinai. The voluntary medical staff, comprised of more than 2,200 specialty board-certified or board-qualified physicians, represent all of the specialties and subspecialties and collaborate with full-time medical staff in the teaching responsibilities of the graduate medical education programs.