We embrace a culture of passion and dedication at Cedars-Sinai, and it's part of the reason we've been named one of the top ten hospitals in America's Best Hospitals by U.S. News & World Report. Now we invite you to join us. From working with a team of exceptional healthcare professionals to using state-of-the-art facilities, you'll have everything you need to do something incredible--for yourself, and for others.
Grow your career at Cedars-Sinai!
Becoming part of a team at the forefont of medicine influences many to join our workforce, as does our dedication to providing the gold standards in care. The unique experience of working at Cedars-Sinai makes people stay.
And right now, our Revenue Integrity & Compliance Team is looking for a Case Management experienced RN to join their department!
What will 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.
Essential job duties:
Oversee CSMC complianc e with government regulations relating to patient status.
Act as liaison and point of contact to/for all government contracted agencies as well as division and other internal representatives for denial and appeal inquiries.
Actively manage, maintain and communicate to appropriate stakeholders denial and appeal activities, trends, and recommended corrective action plans.
Work with team and other CSMC departments to develop data and reports that show KPI for efforts of department.
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, including responsibility for determining qualifications, hiring, terminations, performance management, salary, assigning work, maintaining and improving competence, coaching, training, orientation, in-service and continuing education.
Managers response process for the organization on all government audits including writing of response as appropriate
Manages review of short stay Medicare inpatients for complaints with CMS regulations.
Other key responsibilities:
Acts as contact for all government audit agencies
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 data base 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 (5%)
Works in collaboration.with other departments and health plans to develop corrective action plans to address identified trends in reasons for denials (15%)
Performs case management review of issues related to compliance with government payer coverage issues as well as commercial denials (5%)
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.:5%
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 teaching 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.