This position provides comprehensive assessment, coordination, implementation and reporting of complex clinical data. This position audits medical records on behalf of hospital clients for denials review, defense audits, disallowed charges and retrospective or concurrent reviews. The Supervisor NA, leads and supports the enterprise in utilization management through denials prevention and denials management. The Supervisor, NA brings expert analysis of medical records to inpatient and outpatient claims, assesses the patient’s plan of care and progress of the patient throughout an acute care admission. The intensity of assessment is situational and appropriate based on payer requirements. This position works independently receiving supervision of work activities from the Manager Case Manager. This position supervises and oversees denial management team and collectors on operational changes, quality improvement and staff development across the enterprise.

1. Leadership
   • Provides guidance, mentoring, and direction as appropriate for ongoing staff development and retention. Rotates on-call responsibilities with other assigned staff.
   • With the Medical Director of Utilization Management and Care Management leadership team plans, recommends and implements approved protocols, policies, and guidelines and supports overall organizational values and mission.
   • Participates in hospital and departmental operational initiatives to evaluate and improve reimbursement, denials, level of care, goal length of stay and improve delivery care methods.
   • Functions as part of a leadership team with the Lead CM, Manager of CM and Director of CM on operational changes, quality improvement and or productivity issue for the Care Management Department and HRC Team.
   • Coordinates work activities of assigned staff to ensure achievement of established goals, objectives, and outcomes.
   • Leads employees through ongoing goal setting, training and performance feedback.
   • Evaluates performance of Nurse Auditor, case managers, CMRC and completes performance appraisals.
   • Provides team leadership, demonstrates strong, consistent clear communication and serves as a central point of information informing all team members.
   • Manage all aspects of training and integration of the NA team. Supervise and ensure daily responsibilities are carried out by NA team, provide support and feedback.
   • Cultivates and maintains effective interaction/communication with members of the HRC team, Medical Director and CM UM team.
   • 11. Reviews and analyzes third-party payer denials for in house and outpatient patients and communicates to attending physician, Case Management, Manager, Utilization Management Medical Director and Utilization Management Nurse as per department protocols.
2. Develops Collaborative Health care Team
   • Collaborates with health care team partners on level of care, identified barriers, and other issues that may impact reimbursement.
   • Establishes a collaborative relationship with physicians, medical directors, nurses and other unit staff, Revenue Cycle management and staff, and payers. Mentors internal members of the health care team on utilization management and managed care concepts.
   • Identifies from review of documentation opportunities for increased education with physicians and the health care team.
   • This position performs onsite job duties and responsibilities at Phoenix Children’s Hospital, and is viewed as an accessible member of the health care team.
   • Participates in weekly department process improvement meetings.
3. Regulatory Documentation
   • Participates in various aspects of the revenue-cycle by documenting in AMPFM, SCM, and MIDAS avoidable days, extended length of stay, authorizations, and denials for medical necessity.
   • Performs clinical auditory management in accordance with all state mandate regulations,
   • understands and focuses on key performance indicators, and promptly reports
   • potential denials to health care team.
   • Performs utilization management in accordance with all state mandate regulations,
   • understands and focuses on key performance indicators, and promptly reports
   • potential denials to health care team.
   • Collects data and other information required by payers to fulfill utilization and regulatory requirements.
4. Utilization Management
   • Attends insurance meetings with Utilization Medical Director and Manager, Case
   • Management as needed. Attends Denial Committee meetings with Hospital Revenue
   • Cycle/Physician Revenue Cycle staff as needed.
   • Communicates with Utilization Medical Director all denials requiring a physician to
   • physician conversation.
   • Obtains and reviews medical necessity denial reports. Analysis and documentation for monthly UMRC report. Reports to Hospital Revenue Cycle denial committee findings of report.
   • Increase collaboration with HRC in expediting appeals. Collaborate with interdisciplinary team: pre-access, managed care, HRC, legal, coding/HIM. Ensure follow-through of retrospective and concurrent denial work-flows with all team members. Supervise and utilize reporting capabilities to evaluate efficiency of denials management and quality improvement.
5. Financial Accountability
   • Participates in various aspects of the revenue-cycle by documenting in AMPFM, SCM,
   • and MIDAS avoidable days, extended length of stay, authorizations, and denials for
   • medical necessity. Completes monthly documentation and financial audits as requested by department manager and director.
   • Provides ongoing management of denials and appeals with the Patient Financial
   • Services department. Reports all trends with Case Manager reviews and denial
   • tracking to Manager, Case Management and Director Case Management & Social Service.
   • Responsible for all facets of inpatient denials due to lack of clinical medical necessity
   • for the Case Management department. Communicates and documents all potential
   • denials and non-certified days.
   • Working knowledge of DRG payment system and impact of ICD-10 on physician documentation.
   • Outlier Denials-Oversee, evaluate and appeal outlier denials.
   • Outpatient denials. Supervisor NA to expand scope of denials management to all PCH enterprise inpatient and outpatient locations. Work with pre-access department to manage denial trends. Collaborate with clinics, outpatient surgery centers, etc.
6. Regulatory Responsibilities
   • Reviews the patient daily (Observation and Inpatient) for appropriate status and meeting admission or discharge criteria.
   • Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct ongoing clinical review.
   • Utilizes MCG criteria/guidelines/paths to determine admission status, level of care, goal length of stay and continued provision of services as evidenced by audit of documentation in EMR.
   • Documents avoidable days, extended length of stay, authorizations and denials for medical necessity in EMR and financial applications as evidenced by audit.
   • Communicates to Nurse Auditor and UM team, data supporting denial appeals, or notification of potential denials.
   • Communicates with payers to resolve potential denials.
   • Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct ongoing insurance reviews.
   • Manages a defined service line patient population to achieve optimal outcomes in the most cost-effective manner.
   • Working knowledge of DRG payment methodology and ICD-9/10 coding system.
7. Provides Excellent Customer Service
   • Establishes a collaborative relationship with interdisciplinary team, community providers and Hospital Revenue Cycle management and staff.
   • Provides excellent service routinely in interactions with all customers, .e. co workers, patients, visitors, physicians, volunteers, etc.
   • Responds to emails within 24 hours.
   • Clear communication skills with all internal and external customers.
8. Performs miscellaneous job related duties as requested.

Mission

To advance hope, healing and the best healthcare for children and their families

Vision

Phoenix Children's will be the leading pediatric health system in the Southwest, nationally recognized for exceptional care, innovative research and advanced medical education.

We realize this vision by:

• Offering the most comprehensive care across ages, communities and specialties
• Investing in innovative research, including emerging treatments, tools and technologies
• Advancing education and training to shape the next generation of clinical leaders
• Advocating for the health and well-being of children and families

Values

• We place children and families at the center of all we do
• We deliver exceptional care, every day and in every way
• We collaborate with colleagues, partners and communities to amplify our impact
• We set the standards of pediatric healthcare today, and innovate for the future
• We are accountable for making the highest quality care accessible and affordable