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NYU LANGONE HEALTH is a world-class, patient-centered, integrated academic medical center, known for its excellence in clinical care, research, and education. It comprises more than 200 locations throughout the New York area, including five inpatient locations, a children's hospital, three emergency rooms and a level 1 trauma center. Also part of NYU Langone Health is the Laura and Isaac Perlmutter Cancer Center, a National Cancer Institute designated comprehensive cancer center, and NYU Grossman School of Medicine, which since 1841 has trained thousands of physicians and scientists who have helped to shape the course of medical history. For more information, go to nyulangone.org, and interact with us on LinkedIn, Glassdoor, Indeed, Facebook, Twitter, YouTube and Instagram.

POSITION SUMMARY: We have an exciting opportunity to join our team as a Director, DRG Denials & Appeal. In this role, the successful candidate is responsible for the management and coordination of the DRG Denials and Appeals Process and Specialists. This includes assisting in the overall planning, organization and direction of the daily work assignments for the preparation of DRG Appeals based upon evidence-based criteria documented within the medical record. Conducts analysis of DRG Denials and Appeals, reporting out on identified trends and Revenue Protection opportunities. Maintains expertise by staying up to date on Clinical Practice Guidelines and Coding Regulations that may impact Denial Prevention. Provides Orientation, Training and Education to Clinical Denials and Appeals staff. Develops strong partnerships with HIM, utilizing input from Coding and CDI Specialists as needed. Collaborates with Physicians, Physician Advisors and Clinical Service Line leads for education and compliance. Participates in Enterprise and Hospital based meetings as necessary

JOB RESPONSIBILITIES:

• Develops and implements Standards of Practice for DRG Denials and Appeals Specialists as it relates to formulating and submitting responses to DRG Denials from Commercial Payors, Managed Care and Third Party Review Organizations.
• Manages and prioritizes timely review, investigation and response to DRG Denials and the required actions for appeals within contractual timeframes.
• Conducts ongoing evaluation of DRG Denials and Appeals Specialists as it relates to analysis of adverse determinations, knowledge and application of coding regulations, timely review and response to payor denlias, and maintenance of department metrics.
• Coordinates and collaborates with Content Experts across the enterprise (Physicians, Physician Advisors, Clinical Service Lines, Case Management, Health Infromation Management and Clinical Documentation Improvement, Inpatient and Outpatient Revenue Services, etc.) as needed to obtain necessary documentation and information to support DRG Appeals and implement prevention strategy.
• Assist with developement, maintenance and management of cases utilizing an internal tracking tool for the distribution of reports as requested by Leadership.
• Analyzes and presents monthly denial performance data utilizing case studies with recommendations for Process Improvements at Enterprise - Wide Forums.
• Maintains expertise in clinical validation, coding guidelines, and reimbursement methodologies by practicing in professional organizations, seminars and educational programs.
• provides orientation, training and education to DRG Denials and Appeals Specialists as well as participates in hospital-wide forums as needed.
• Perform other duties as assigned.

MINIMUM QUALIFICATIONS: To qualify you must have a Bachelor's degree in Nursing or Health Information Management or other health related field. 5-7 years of Coding and Clinical Validation experience including acute care hospital experience in medical record chart review and current experience with reimbursement methodologies. Certified Coding Specialist Certification. Demonstrates and maintains ongoing responsibility for professional development . Ability and willingness to work a flexible schedule to ensure compliance with deadlines. Strong communication (verbal and written) and interpersonal skills. Ability to communicate with multiple levels of the organization: Senior Leadership, Physicians, Directors, Clinical and Support Staff. Demonstrates strong critical thinking and analytical skills. Ability to work collaboratively in a team environment. Demonstrates the ability to handle multiple assignments and carry out work independently with minimal supervision. Proficient with Microsoft applications and working knowledge of EPIC and other hospital based clinical computer systems.. REQUIRED LICENSES: Certified Coding Specialist

PREFERRED QUALIFICATIONS: Master's degree in Nursing (or other health related field) or Health Information Management. Experience preparing appeals for DRG Denials. Certification in Clinical Documentation Improvement.

Qualified candidates must be able to effectively communicate with all levels of the organization. NYU Langone Health provides its staff with far more than just a place to work. Rather, we are an institution you can be proud of, an institution where you'll feel good about devoting your time and your talents. NYU Langone Health is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, gender, gender identity or expression, sex, sexual orientation, transgender status, gender dysphoria, national origin, age, religion, disability, military and veteran status, marital or parental status, citizenship status, genetic information or any other factor which cannot lawfully be used as a basis for an employment decision. We require applications to be completed online. If you wish to view NYU Langone Health's EEO policies, please click here. Please click here to view the Federal EEO is the law poster or visit for more information. To view the Pay Transparency Notice, please click here.

Required Skills Required Experience