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Job Description
Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect.
Whether virtual or on campus, Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work.
Job Summary:
Leads, directs, designs and evaluates operations and outcomes of critical and key functions for the Clinical Resource Management Center (CRMC). Manages planning, design and functionality and deployment of associated processes, and usage of Veracity tool (system-wide denial management tool). Directs & prioritizes the IT ticketing process for the department and facilitates resolution. Manages & maintains payer relationships to drive issue resolution and improved financial outcomes, and coordinates joint operating committees with the payer community. Identifies trends and barriers to successful flow through. Acts as liaison between and with peripheral departments (patient access, financial clearance, PFS, etc.) to ensure quality inflow (and outflow) of information to drive critical CMRC functions. Optimizes and gatekeeps critical process flows within the department and hand-offs with outside departments along with supporting job aides and training materials. Possesses strong subject matter expertise in both utilization review and revenue cycle functions to support a diverse and complex operating environment and span of control. Manages the denials and appeals process with third party payers and assists with development of utilization review and resource management programs based on the changing requirements or new contractual arrangements with third party payers. Manages and maintains reporting and analytics for the department including initial denials, final write-offs, operational metrics and ad-hoc analyses.
Job Requirements:
Education and Work Experience:
Organizational Requirements:
Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.
About Us
Adventist Health is a faith-based, nonprofit, integrated health system serving more than 90 communities on the West Coast and Hawaii with over 400 sites of care, including 26 acute care facilities, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of 37,000 includes employees, physicians and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.
Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect.
Whether virtual or on campus, Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work.
Job Summary:
Leads, directs, designs and evaluates operations and outcomes of critical and key functions for the Clinical Resource Management Center (CRMC). Manages planning, design and functionality and deployment of associated processes, and usage of Veracity tool (system-wide denial management tool). Directs & prioritizes the IT ticketing process for the department and facilitates resolution. Manages & maintains payer relationships to drive issue resolution and improved financial outcomes, and coordinates joint operating committees with the payer community. Identifies trends and barriers to successful flow through. Acts as liaison between and with peripheral departments (patient access, financial clearance, PFS, etc.) to ensure quality inflow (and outflow) of information to drive critical CMRC functions. Optimizes and gatekeeps critical process flows within the department and hand-offs with outside departments along with supporting job aides and training materials. Possesses strong subject matter expertise in both utilization review and revenue cycle functions to support a diverse and complex operating environment and span of control. Manages the denials and appeals process with third party payers and assists with development of utilization review and resource management programs based on the changing requirements or new contractual arrangements with third party payers. Manages and maintains reporting and analytics for the department including initial denials, final write-offs, operational metrics and ad-hoc analyses.
Job Requirements:
Education and Work Experience:
- Bachelor's Degree in business or equivalent combination of education/related experience: Required
- Master's Degree in business or equivalent combination of education/related experience: Preferred
- Five years' acute care hospital experience: Required
- Three years' revenue cycle experience: Preferred
- Five years' leadership experience: Preferred
- Manages ongoing analysis, development, and implementation of methods and systems to improve overall effectiveness of the authorization processes. Identifies opportunities to improve inpatient authorization workflows, communication amongst payers, providers, and organizations. Sets and monitors performance targets. Collaborates with clinical CMRC director on hand-offs between teams and support functions to drive optimal financial outcomes.
- Supports clinical CMRC team on process redesign, analytics, and distribution of operational metrics. Prepares, presents and analyzes outcomes data and recommends and executes continual process and quality improvement initiatives. Communicates findings, opportunities and outcomes via presentations, data analysis and ongoing education to various stakeholders throughout the organization.
- Coordinates with other revenue cycle stakeholders to develop an integrated workflow that supports payment for clinical services provided. Collaborates with coding, care management, clinical documentation improvement, patient financial services, managed care, and quality managers to ensure that organizational goals, business objectives, and regulatory needs and requirements are being met. Identifies educational opportunities for healthcare team.
- Oversees staff including training, performance, competencies, productivity, and ongoing education. Delivers ongoing coaching, mentoring, and support to direct reports. Resolves issues and addresses staff, patient, and provider concerns.
- Stays abreast of regulatory changes and payer policies. Maintains confidentiality of information in compliance with hospital policies and HIPAA.
- Performs other job-related duties as assigned.
Organizational Requirements:
Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.
About Us
Adventist Health is a faith-based, nonprofit, integrated health system serving more than 90 communities on the West Coast and Hawaii with over 400 sites of care, including 26 acute care facilities, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of 37,000 includes employees, physicians and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.