Supervisor, Managed Care Audits and Appeals Recovery

Responsibilities:

• Direct and oversee incoming Managed Care payer audit process utilizing COBIUS system, or other assigned system.
• Analyze and validate audit findings for accuracy within specific payer contract terms.
• Dispute erroneous findings directly with third party auditors/payers, while keeping UPHS management and responsible staff informed.
• Ensure audits are addressed in a timely manner to avoid payment retractions.
• Correspond with key personnel in multiple areas within UPHS, including but not limited to CRM, HIM, Patient Access, Patient Accounting and Managed Care concerning trends in found issues.
• Participate in payer meetings to discuss problematic accounts.
• Refer accounts to outside collection attorney on cases which have reached an impasse.
• Orchestrate concise and compelling appeals in the administrative denial of large dollar (> $5k) cases.
• Assist in, and share in the responsibility of UPHS Management in attaining yearly cash collection goals.
• Document monthly audit activity, report potential loss and recoverable revenue through dispute resolution.
• Maintain close contact close contact with the staff of HIM, CRM and Patient Accounting to ensure all issues relating to Managed Care audits are being addressed.
• Review incoming third party reimbursement audits with a heavy focus on DRG Reassignments and IP Level of Care
• Thoroughly document each case in EPIC, Date of Audit, Audit Company conducting audit and detailed findings related to clinical validation of Coding or Level of Care.
• Facilitate timely issuance of audits to the Health Information and Clinical Resource Management staff of the five PennMedicine Hospital Facilities to ensure timely appeals.
• Ensure all work entering the HB Audit Workqueue in Onbase is completed within the same day received and/or no later than the next business day.
• Forward Coordination of Benefits Audits to A/R Team Representative to verify eligibility/initiate billing of new insurance.
• Dispute any invalid/erroneous audit back to Third Party Auditors and Payer Network Representatives.
• Inform Penn A/R Management, Contracting and Contracted Payers of ongoing negligence / erroneous audits that are in violation of our contracts.
• Perform as System Administrator for the DPW Epromise system.
• Fulfill requests for E-Promise system sign-ons for new Penn and A/R vendor employees
• Assist in the completion of PA MA Revalidations of all Penn hospital service locations, specifically providing/inputting required confidential Hospital Board Member information in the online revalidation applications.
• Act as an intermediary between Penn Medicine Clinical Staff, A/R Staff and Contracted A/R vendors in assisting in the resolution of problematic cases.
• Performs duties in accordance with Penn Medicine and entity values, policies, and procedures.
• Other duties as assigned to support the unit, department, entity, and health system organization.

Education/ Experience:

• H.S. Diploma/GED (Required).
• 5+ years of Revenue Cycle experience for a multi hospital facility (Required).

Skills & Abilities:

• Highly effective verbal and written communication skills.
• Ability to deal professionally with all levels of internal and external staff and management.
• Proven ability to understand and assimilate multiple contract nuances across all payers.