Program Integrity Appeals Manager

Additional Information About the Role Join our team in a dynamic leadership role focused on managing complex healthcare appeals and driving revenue recovery across the organization. Enjoy the flexibility of a fully remote work environment along with a flexible schedule , allowing you to balance professional success with personal priorities while making a meaningful difference. Overview BJC HealthCare is one of the largest nonprofit health care organizations in the United States, delivering services to residents primarily in the greater St. Louis, southern Illinois and southeast Missouri regions. With net revenues of $6.3 billion and more than 30,000 employees, BJC serves patients and their families in urban, suburban and rural communities through its 14 hospitals and multiple community health locations. Services include inpatient and outpatient care, primary care, community health and wellness, workplace health, home health, community mental health, rehabilitation, long-term care and hospice. BJC is the largest provider of charity care, unreimbursed care and community benefits in the state of Missouri. BJC and its hospitals and health service organizations provide $785.9 million annually in community benefit. That includes $410.6 million in charity care and other financial assistance to patients to ensure medical care regardless of their ability to pay. In addition, BJC provides additional community benefits through commitments to research, emergency preparedness, regional health care safety net services, health literacy, community outreach and community health programs and regional economic development. BJC's patients have access to the latest advances in medical science and technology through a formal affiliation between Barnes-Jewish Hospital and St. Louis Children's Hospital with the renowned Washington University School of Medicine, which consistently ranks among the top medical schools in the country. Preferred Qualifications Role Purpose Responsible for the design, development, administration and management of appeals related to all government healthcare program integrity auditors, along with appeals related to non-contracted managed care claim denials. This responsibility will include but is not limited to collaboration with attorneys, physicians, case managers, revenue cycle personnel and payers to appeal denials. Responsible for designing an appeals paradigm to establish the parameters for appeals, based on the matter, cost, history, and likelihood of success. The incumbent will work with consultants and legal counsel (internal/external) to represent the interests of BJC in the appeals process through the five stages of appeals, including administrative and judicial review. Additionally, the position is responsible for designing and implementing audit plans to help assess and ensure BJC's compliance with billing issues, including those related to medical necessity and non-covered services, as defined by government payors. The Manager is a member of BJC's Compliance and RAC Teams and fully participates in conducting investigations, researching regulatory issues and delivering applicable compliance education. Responsibilities Manages individual(s) including but not limited to: hires, trains, assigns work, manages & evaluates performance, conducts professional development plans. Ensures that the productivity and actions of that group meet/support the overall operational goals of the department as established by department leadership. Designs, develops and implements BJC's integrity appeals program. Administers and directs the appeals process by communicating directly with program integrity audit contractors. Designs, develops and manages medical necessity audits, including those related to observation and one-day stay billing. Develops processes and policies for effectively tracking and managing audit denials and evaluates internal and external systems for enhancing efficiencies. Minimum Requirements Education High School Diploma or GED Experience 5-10 years Supervisor Experience 2-5 years Preferred Requirements Education Bachelor's Degree - Bus/HC Admin/Nursing/related Experience 10+ years Benefits and Legal Statement BJC Total Rewards At BJC we're committed to providing you and your family with benefits and resources to help you manage your physical, emotional, social and financial well-being. Comprehensive medical, dental, vison, life insurance, and legal services available first day of the month after hire date Disability insurance• paid for by BJC Annual 4% BJC Automatic Retirement Contribution 401(k) plan with BJC match Tuition Assistance available on first day BJC Institute for Learning and Development Health Care and Dependent Care Flexible Spending Accounts Paid Time Off benefit combines vacation, sick days, holidays and personal time Adoption assistance To learn more, go to our Benefits Summary . •Not all benefits apply to all jobs The above information on this description has been designed to indicate the general nature and level of work performed by employees in this position. It is not designed to contain or be interpreted as an exhaustive list of all responsibilities, duties and qualifications required of employees assigned to this job.

Equal Opportunity Employer Qualifications:

Role Purpose Responsible for the design, development, administration and management of appeals related to all government healthcare program integrity auditors, along with appeals related to non-contracted managed care claim denials. This responsibility will include but is not limited to collaboration with attorneys, physicians, case managers, revenue cycle personnel and payers to appeal denials. Responsible for designing an appeals paradigm to establish the parameters for appeals, based on the matter, cost, history, and likelihood of success. The incumbent will work with consultants and legal counsel (internal/external) to represent the interests of BJC in the appeals process through the five stages of appeals, including administrative and judicial review. Additionally, the position is responsible for designing and implementing audit plans to help assess and ensure BJC's compliance with billing issues, including those related to medical necessity and non-covered services, as defined by government payors. The Manager is a member of BJC's Compliance and RAC Teams and fully participates in conducting investigations, researching regulatory issues and delivering applicable compliance education. Responsibilities Manages individual(s) including but not limited to: hires, trains, assigns work, manages & evaluates performance, conducts professional development plans. Ensures that the productivity and actions of that group meet/support the overall operational goals of the department as established by department leadership. Designs, develops and implements BJC's integrity appeals program. Administers and directs the appeals process by communicating directly with program integrity audit contractors. Designs, develops and manages medical necessity audits, including those related to observation and one-day stay billing. Develops processes and policies for effectively tracking and managing audit denials and evaluates internal and external systems for enhancing efficiencies. Minimum Requirements Education High School Diploma or GED Experience 5-10 years Supervisor Experience 2-5 years Preferred Requirements Education Bachelor's Degree - Bus/HC Admin/Nursing/related Experience 10+ years