POSITION SPECIFICATION September 2014

POSITION:Director of ICD-10 & Denials Management

ORGANIZATION:

Hospital for Special Surgery (HSS) was founded in 1863 and is recognized as a world leader in musculoskeletal medicine. Though located in New York City, HSS treats patients from throughout the New York City Metropolitan Area, New York State, the United States, and 90 countries who seek its internationally recognized specialized care. HSS has 205 beds and 35 operating rooms and performs more than 29,000 surgeries per year. In addition, it handles more than 360,000 non-surgical outpatient visits annually. HSS is forecasting average annual surgical-volume growth of 4-5 percent per year over the next five years. It is an affiliate of the New York-Presbyterian Healthcare System and Weill Cornell Medical College. It has one of the most sought-after residency programs and its graduates hold prominent positions in hospitals throughout the country.

HSS has been a leader in pioneering new procedures, including: pioneering the modern total knee replacement; designing a revolutionary fiber optic probe for distinguishing healthy and diseased cartilage during surgery; developing new imaging protocols for MRI evaluation of cartilage; pioneering the development of minimally invasive spine surgery techniques that eliminate the need for spinal fusion; perfecting surgical techniques for minimally invasive hip and knee procedures, minimizing hospital stays for qualified patients; and leading the world in the application ofregional anesthesia techniques.

The Hospital’s research division occupies an influential position in the world of musculoskeletal science. A major goal of the research division is to foster translational research through the establishment of teams that bring clinicians and basic scientists together to solve disease-related problems and to translate research findings and accomplishments into new technologies that improve patient care and outcomes.

HSS’s excellence in patient care and innovation is reflected in the many awards and recognitions it has received. HSS is nationally ranked No. 1 in orthopedics, No.4 in rheumatology, and No.5 in geriatrics by U.S. News & World Report (2013-14) and is the first hospital in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center three consecutive times. HSS has one of the lowest infection rates in the country. From 2008 to 2012, HSS was a recipient of the HealthGrades Joint Replacement Excellence Award.

HSS physicians are team doctors for the New York Mets, New York Giants, New York Knicks, New York Liberty, and New York Red Bulls. HSS is the Official Hospital of The PGA of America, New York Road Runners for the ING New York City Marathon, St. John’s Athletics, CUNY Athletic Conference, and other professional and college teams.HSS has been designated as the first National Medical Center of the United States Olympic Committee’s National Medical Network.

For more information on Hospital for Special Surgery, please visit its website: .

POSITION OVERVIEW:
The Director of ICD-10 & Denials Management will have responsibility for both functional areas. Due to the revised date for conversion to ICD 10, the position will focus initially around responsibilities for managing denials.
ICD-10

The Director will be the project manager for the hospital’s transition from ICD-9 to ICD-10. Working with internal and external resources, s/he will continue the implementation of the ICD-10 project plan to include all activities and deliverables for a successful conversion to ICD-10 by the October, 2015.

This position will interface with the numerous departments and functions within the hospital that will be impacted by this change. The Director will lead cross-functional teams, ensuring that all project requirements are well communicated by team members, resulting in the successful delivery of key project milestones. In coordination with IT, HIM, Revenue Cycle, Finance, and other functions, the Director will identify core issues and risks and recommend mitigation and response solutions to ensure that the implementation plan stays on schedule, on budget and achieves prescribed goals. The Director is responsible for coordinating RAC audits and all coding reviews to ensure proper maintenance of quality coding.

Denials Management

The Director will direct, monitor, and evaluate denial activity from a system perspective. S/he will be responsible for reporting denial activity with financial implications, identifying current patterns and trends, and providing recommendations to minimize or avert future denials. S/he will develop proactive denial-prevention strategies that will decrease denials overall, such as contract language, patient-access-process changes, case management collaboration, appeal opportunities, etc.

The Director will work cooperatively with the Compliance Department in the assessment and formulation of benchmark denial-prevention strategies and foster effective communications and implementation of best practices and accounting services. Also, s/he will provide insight into national and local coverage determinations that may be questionable or unreasonable in the application in the clinical setting. In addition to the implementation of successful appeal efforts, the ongoing analysis of denials will provide a guide for methodical and strategic process improvement to initiate process enhancement aimed at the prevention/avoidance of each subsequent denial.

The Director of ICD-10 & Denials Management will manage a department of 3 professionals: Project Manager, ICD 10 Manager, and ICD 10 Analyst.H/she will report to the VP, Revenue Cycle.

RESPONSIBILITIES: The specific responsibilities include, but are not limited to:

ICD-10

  • Provide project leadership and management for the ICD-10 initiative, resulting in the successful hospital-wide conversion to ICD-10 by October, 2015.
  • Develop an internal communication plan that effectively rebuilds awareness of this initiative hospital-wide and creates a sense of urgency by key parties, especially physicians, regarding actions they need to take to help facilitate the change.
  • Develop an extensive understanding of the priorities and critical initiatives of both the institution and the Finance Department, especially Revenue Cycle, to better inform the implementation of the ICD-10 plan.
  • Engage appropriate stakeholders to drive the creation of all project milestone deliverables; facilitate review and approval process with ICD-10 Steering Committee and ICD-10 executive sponsors.
  • Using leading project management methodology, manage the project workflow and life cycle, ensuring that deliverables are met on time and on budget; continually measure progress against established metrics.
  • Report project status to supervisor and other financial/executive leadership, as required. Manage new priorities and adjustments to project plan efficiently and effectively.
  • Establish strong working relationships with financial leadership and colleagues and key personnel of interfacing departments, as required.
  • Create and lead cross-functional teams, made up of representatives of all critical functional areas. As team leader, provide proper engagement and oversight of the project, resulting in assignment of specific tasks to individuals and/or departments, accountability for project work deliverables, excellent communication of project status, and timely identification of key issues and corresponding action plans.
  • Identify ICD-10 training needs and develop the associated curriculum for training all staff on the coding changes and new procedures required to properly use the ICD-10 system. Coordinate the ICD-10 training of inpatient and outpatient coders.
  • Analyze the impact of documentation gaps on reimbursement and patient severity under ICD-10; develop an ICD-10 clinical-documentation-improvement education strategy for the medical staff and departments to ensure that revenue-enhancement goals are achieved.
  • Monitor redesign of clinical and business processes and confirm the approach for tracking and communicating performance improvement in accordance with business-case commitments.
  • Implement issue-resolution and risk-mitigation processes; ensure that issues are resolved or escalated to appropriate forums for resolution; identify barriers to project success and facilitate risk management planning.

Denials Management

  • Evaluate each patient medical record,noting discrepancies in over-under- and miss-billed items; correctly calculate the dollar total amounts for each discrepancy and submit necessary documents for patient accounts adjustment.
  • Communicate regularly with clinical and administrative personnel to obtain further supportive documentation for billed services beyond what is found in the medical record.
  • Conduct hospital billing audits to assure billing for all chargeable services.
  • Work with external auditors to assure that uncompensated patient revenues resulting from audits of patient-service billings (claims) are minimized; negotiate with external auditors regarding billing issues to reach agreement on disputed items; provide appropriate supportive documentation for questioned charges.
  • Apply the clinical documentation process to auditing to effectively maximize the hospital’s position in negotiation.
  • Identify acceptable versus unacceptable supportive information, based on JCAHO/AHA/Clinical Practice Standards.
  • Provide timely information regarding bill-defense problems to supervisor, and offer recommendations to eliminate the unnecessary loss of revenue.
  • Oversee the coordination of all administrative activities with regard to denial management; collect all denial correspondence; update the denial database regularly; coordinate appeals process; aggressively appeal denials.
  • Prepare reports on payer-denial activity for use in payer meetings to resolve accounts; assist in preparing and coordinating follow-up activities to resolve organizational difficulties with regard to denials.
  • Participate in departmental projects and educational opportunities to enhance the effectiveness of the Denials Management Department; develop and/or coordinate ongoing training sessions for revenue cycle staff, clinical staff, etc.
  • Maintain current clinical knowledge through reading, attendance at seminars, clinical practice, and informal sessions with other departments.

EDUCATION AND CERTIFICATIONS:

  • A bachelor’s degreeis required, preferably in a healthcare-related field.
  • An advanced degree is a plus, but not required.
  • AHIMA ICD-10-CM/PCS training instructor required; ICD 10 certification (or working towards certification) required
  • AHIMA or AAPC certification required (CCS, CCS-P, CPC, CPC-P, CPC-H, CPMA, CDIP)
  • Completion of a clinical program required - Registered Nursing Program is preferred.
  • A minimum of three years current clinical experience is required. Clinical experience in a specialty area is preferred (e.g., Orthopedics or OR).
  • Project Management Professional (PMP/PMI) certification is highly desired but not required.

EXPERIENCE AND COMPETENCIES:

General

  • 10 years’ progressive work experience in health care, with a minimum of 5 years’ both hospital and ambulatory revenue cycle experience, required.
  • Major teaching/surgical hospital experience is highly desirable.
  • Ability to work with a diverse group of clinicians, ancillary departments, and office staff.

ICD 10

  • Thorough knowledge of charge capture, claims, remittance, denial management processing.
  • Knowledge of contract management processes preferred.
  • Experience in auditing revenue & payer contract performance preferred.
  • Demonstrated accomplishments for revenue cycle initiatives and the implementation/ support of solutions with some consulting experience in revenue cycle or coordinating a multidisciplinary audit team.
  • Specific ICD-9/ICD-10 system conversion experience is highly desired. Additional experience with complex hospital systems upgrades or installations and IT/HIM/financial interfaces are a plus.
  • Experience dealing with third-party coding reviews and audits.
  • Highly analytical and process driven; possesses a solid understanding of revenue cycle and quality improvement.
  • Technology and system savvy: excellent understanding of processes, systems, coding (CPT/HCPCS) and databases. Knows how to use these efficiently and effectively. Familiarity with Eagle and Star systems is a plus.

Denials Management

  • Effective negotiating skills, including the ability to resolve difficult claim issues; ability to apply clinical-assessment skills to the medical record and extract supportive documentation for audit purposes.
  • Understanding and application of patient-care protocols (standards of regulatory and accrediting) in order to interpret care rendered with regard to billing practices.
  • Ability to convey information successfully to clinicians, as well as to outside auditors, and to document accurately and completely.
  • Knowledge of Patient Access (Registration & Patient Scheduling) workflow processes.
  • Expert knowledge of ICD-9, ICD-10, CPT and HCPC coding, DRGs and APCs.
  • Understanding of current billing and regulatory requirements, including federal compliance regulations and coding guidelines.

PERSONAL CHARACTERISTICS

  • Exceptional interpersonal and influencing skills; success at cultivating strong relationships with internal stakeholders and creating partnerships throughout the organization. Experience working with executive and medical leadership, especially physicians and their offices.
  • Well organized and disciplined; can work independently and lead large organizational initiatives and teams through proper engagement and involvement to achieve desired results.
  • Resolves issues through innovative problem solving and solution development; capable of gaining commitment to project goals.
  • Stays current on healthcare industry trends and reform; can identify potential impacts and/or problems that may arise during conversionand translatethem into remedial action plans.
  • Outstanding communication skills: succinct and easy to understand,a good listener, skilled at influencing a variety of people.Capable of developing and implementing educational programs for a diverse audience.
  • Smart and insightful, mentally tough and resilient.Remains calm in a crisis. Highly confident, results-driven person who is focused on achieving the goals of the organization.
  • Unquestionable personal integrity. Exudes credibility and professionalism. Very likeable. Quickly builds confidence in others. Team player and understands his/her role in relationship to others.
  • A highly committed individual, with the necessary drive and stamina to successfully oversee both denials management and the ICD-10 conversion.

COMPENSATION:

The compensation and comprehensive benefit package is competitive. The position offers opportunities for advancement.

APPLICATIONS AND REFERRALS:

Applicants should send a current resume in Word format and a summary of relevant experience/credentials to:

(Ms.) Dale Corey

Director of Research

3D Leadership, LLC

HSS is committed to diversity among its employees and encourages candidates from all backgrounds to apply.

1 HSS Director of ICD-10 & Denials Management3D Leadership, LLC