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Operations Manager RN Denials Prevention Hospital Claims - FL #3341

Anderson Recruiting Associates
Miami, Florida, United States
January 13, 2017

Posted By Premium Recruiter


Operations Manager RN needed! Job #3341

Location: Miami Florida

Compensation: Competitive

Relocation: Not Available

Position Summary: Responsible for working with Hospital client's assigned staff and internal denials team to evaluate denials and appeals management, root causes and client's revenue cycle processes with creation of process improvements to reduce and prevent payor denial of claims.

General Purpose: Client relations; problem resolution; critical thinking; process improvement; data analysis; relationship building

Essential Duties and Responsibilities:

* Evaluate revenue cycle operations including analysis of root causes, identification of areas for process improvement, education of staff and evaluation of metrics and outcomes to measure success

* Analyze monthly reports by trends, hospital, payor and reason in order to identify operational issues causing denials

* Work with all applicable departments and staff including revenue cycle and case management departments at each hospital and the business office to establish best practices related to denials prevention

* Review managed care contracts, hospital billing statements/bills and insurance denials

* Communicate with hospital and payor personnel concerning all issues relating to denials

* Present initiatives and results at meetings

* Serve as a liaison between clinical and financial teams while facilitating and driving change for process improvement

* Maintain confidentiality of information in compliance with company policy and HIPAA

* Maintain regular contact with necessary parties including payors, clients, managers, and other personnel

* Build strong, lasting relationships with clients, payors and personnel

* Attend client, department and company meetings

* Comply with federal and state laws, company policies and procedures

* All other duties as assigned

Essential Skills and Experience:

* Must have current RN license, BSN preferred

* Clinical nursing experience working in hospital environment, preferably in ER, ICU, Med-Surg,Psych and/or Transplant unit

* Experience with Milliman care guidelines and/or InterQual clinical criteria preferred

* Revenue cycle experience as it relates to clinical operations

* Overall hospital operations experience with multi-disciplinary teams

* Moderate computer proficiency, including working knowledge of Microsoft Word and Excel

* Excellent interpersonal and communication skills

* Experience with performance improvement tools such as variance/root cause analysis, data interpretation, flow charting and metric development

* Mathematical skills: ability to calculate rates using addition, subtraction, multiplication and division

* Ability to read and interpret an extensive variety of documents such as contracts, claims, instructions, policies and procedures in written (in English) and diagram form

* Ability to write routine correspondence (in English)

* Ability to define problems, collect data, establish facts and draw valid conclusions

* Strong customer service orientation

* Strong team player

* Commitment to company values

* Ability to travel among the system hospitals to work with personnel in the hospitals and central business office

BOTTOM-LINE REQUIREMENTS: (Candidates must answer)

1. RN required. BSN preferred.


2. Clinical nursing experience working in hospital environment, preferably in ER, ICU, Med-Surg or Transplant Unit.


3. Claims Denials experience


4. Revenue cycle experience as it relates to clinical operations.


5. Overall hospital operations experience with multi-disciplinary teams


6. Experience with Milliman care guidelines or InterQual clinical criteria preferred.


Please send resume in Word format to as an attachment and include salary, phone number and reference Job #3341. candidates must also provide responses to the employer's BOTTOM-LINE REQUIREMENTS