Fraud Prevention Manager manages a team of analysts responsible for the detection, prevention, and mitigation of fraudulent transactions. Develops cross-functional initiatives to proactively detect and prevent fraud from occurring. Being a Fraud Prevention Manager approves and implements recommendations for process and procedure improvements. Reviews and implements best practices in the fraud prevention industry. Additionally, Fraud Prevention Manager ensures compliance with all relevant anti-fraud regulations and standards. Creates reports outlining trends, risks, and mitigation strategies. Requires a bachelor's degree. Typically reports to a director. The Fraud Prevention Manager manages subordinate staff in the day-to-day performance of their jobs. True first level manager. Ensures that project/department milestones/goals are met and adhering to approved budgets. Has full authority for personnel actions. To be a Fraud Prevention Manager typically requires 5 years experience in the related area as an individual contributor. 1 - 3 years supervisory experience may be required. Extensive knowledge of the function and department processes. (Copyright 2024 Salary.com)
Reporting to the System Director of Revenue Cycle Integrations & Denial Prevention, the Manager will lead and manage the department and teams responsible for addressing system-wide denials related to authorizations, notifications, non-coverage, medical necessity, level or care, and others as assigned. You will create an efficient and effective denials and appeals workflow, and optimize revenue recovery. This role works collaboratively across the organization to identify opportunities for workflow and process improvement, set goals, measure process effectiveness and productivity, and implement needed policies.
Denials Management• Works collaboratively with leadership, medical staff, inter-disciplinary team members and revenue cycle entities to ensure optimal reimbursement and regulatory compliance
• Leads multi-disciplinary work groups, manages denials management forums and communicates denial trends to Leadership, Case Management, Utilization Review, Managed Care, Revenue Cycle, Physician Advisors, Hospital Departments, and Clinics, etc.
• Reviews and analyzes current audit information to educate colleagues both internal and external to the revenue cycle.
• Identifies, and initiates clinical quality improvement initiatives focused on improving both clinical quality indicators/outcomes and financial metrics.
People Management• Oversees System-wide Denial staff.
• Performs or oversees personnel management functions. Provides training and support to Denials staff.
• Hires, provides performance assessments and feedback, and develops staff.
• Conducts timely performance reviews and provides on-going feedback.
• Establishes and monitors individual and team goals and objectives.
• Approves time and PTO requests.
• Creates opportunities to celebrate the accomplishments of staff, providers and peers.
• Challenges people, ideas, and opinions to develop the best possible support.
• Quality management, workforce planning, recruiting, coaching and training.
• Performance is demonstrated through continuous staff development, and employee engagement.
Compliance and Safety• Interprets and implements complex rules and regulations governing insurance, appeal activities, trends, etc. to make recommendations
• Monitors and tracks meaningful metrics to assess performance (effectiveness, efficiency) of denials management workflows and validates KPIs and triggers process improvement efforts pro-actively based on performance targets
• Develops and manages initiatives to ensure the operations of the denials management teams is in line with organizational goals
EducationBachelor's Degree in realted healthcare field Preferred
Certification & LicensuresN/A
Experience• Minimum of seven years of progressive experience in appeal/denial management required.• Ability to analyze and resolve problems; manage multiple priorities; prepare reports; organize, direct and evaluate work of assigned staff; utilize a variety of electronic software applications including hospital financial management systems. Healthcare is a rapidly changing environment and technology is integrated into almost all aspects of patient care. Computers and other electronic devices are utilized across the organization and throughout each department. Colleagues must have an understanding of computers, and competence in using computers and basic software programs.
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