• The Director Denials Management provides leadership for the audit, appeal and review process to preserve and recover revenue while maintaining the highest level of clinical and regulatory integrity and compliance
• Manages the Denials Management data analytics, denial and appeal process
• The Director, Home Health Grievances & Appeals assists members, via phone or face to face, further/support quality related goals
• Investigates and resolves member and practitioner issues

Decisions are typically related to the implementation of new/updated programs or large-scale projects for the function and supporting technical/operational procedures and processes, and implements strategic plans, drives goals and objectives, and improves performance

• Provides input into functions strategy
• Oversee the process for direction and support to clinical and operational leadership regarding Medicare and governmental audit trends, denials, and any CMS initiative and/or demonstration projects
• Collaborates with leadership team in the development of an education plan to improve processes to preserve and recover revenue
• Analyzes region-wide outcome indicators to measure achievement of quantitative and qualitative standards
• Assists in the development, implementation and analysis of internal and external benchmarking programs to measure the region's effectiveness in improving performance
• Maintains region-wide Performance Improvement program which includes Customer Satisfaction, complaints, infection monitoring, Incident Reporting, and quarterly branch PI activity
• Provides feedback and recommendations for changes to policies and processes, procedures and systems to enhance measures taken to improve performance
• Communicate with Corporate leadership, Regional and Divisional leaders as appropriate to resolve issues that may place patients or the company at risk
• Oversee educational in-services based on analysis of PI data and activities Acts as a resource for the Operations Support team and communicates Performance Improvement results
• Participate in special projects and performs other duties as assigned
• Knowledge in the interpretation and application of regulations and performance improvement standards
• Approximate percent of time required to travel: 30%
• Performs other related duties as assigned
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
• Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required

Scheduled Weekly Hours

• Bachelor's degree in Nursing or related field
• 10-15 years progressively responsible experience in home health or hospice industry that includes performance improvement and outcomes measurement
• 5 years' experience in a supervisory or teaching role
• Thorough knowledge of health care policy, industry and related clinical practice
• Strong Project management principles and clinical policy development/implementation required
• Expert knowledge of all Medicare regulations and appeals processes
• Excellent analytical skills with ability to interpret and apply regulatory requirements
• Excellent verbal/written communication and presentation skills
• Must be able to work well independently and in a team environment
• Excellent communication and organization skills
• Strong attention to detail
• Must read, write and speak fluent English
• Must have good and regular attendance
• To Ensure Home Or Hybrid Home/Office Employees' Ability To Work Effectively, The Self-provided Internet Service Of Home Or Hybrid Home/Office Employees Must Meet The Following Criteria
• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested

Satellite, cellular and microwave connection can be used only if approved by leadership

Advanced knowledge with Payer requirements, ADR requests, Denials, Appeals, RAC/ZPIC and CERT responses

• Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense
• The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting

The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc $126,300 - $173,700 per year

• This job is eligible for a bonus incentive plan
• This incentive opportunity is based upon company and/or individual performance
• Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being
• Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work

Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities