Reports to the Chief Utilization Officer (CUO) of Henry Ford Health, responsible for Clinical Denial Recovery Unit (CDRU) operations. Responsible for strategic and operational leadership and oversight of programs and initiatives including denials management, performance improvement, regulatory, compliance, and risk with an expectation of national top decile performance. This system role includes physician oversight and clinical input for post-discharge medical necessity denials at all HFHS acute care facilities.
Oversee a comprehensive value-driven centralized denial management process.
In collaboration with executive and administrative partners, provide clinical expertise to CDRU, Payor Audit, hospital UM teams, system IPAS, managed care contracting, and legal.
Participate as a clinical expert in payer negotiations and escalations, Accounts Receivable Reconciliation Group (AARGs) and Medical Director Meetings (MDMs), and during Administrative Law Judge (ALJ) hearings for denied cases.
Standardize and oversee a comprehensive reliability-driven process for status determination in concert with site level physician advisors.
Prepare and analyze denial metrics and make recommendations for process improvements.
Provide feedback to system IPAS regarding denial trends, opportunities for improvement, and payor practices.
Report out metrics and initiatives at Medical Executive and Executive Leadership meetings as requested.
Assist the manager of CDRU, UM Director, and Director of Payor Audit with preparation of case escalations for payer negotiations.
Assist the CDRU RN staff with medical necessity appeals for complex medical cases.
Maintain a working knowledge of applicable Federal, State and local laws and regulations, initiatives, and expectations as set by payers and CMS.
Collaborate with accountable leaders to develop processes that ensure consistent feedback for all involved care providers regarding specific denial mitigation strategies and performance results.
Medical Director - Clinical Denial Recovery Unit (CDRU)/Payor Audit • Detroit, MI, United States
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