PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Hospital - Whittier, PIH Health Hospital - Downey and PIH Health Good Samaritan Hospital, 27 outpatient medical locations, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, women’s health, urgent care and emergency services. The organization is recognized by Watson Health as one of the nation’s Top Hospitals, and College of Healthcare Information Management Executives (CHIME) as one of the nation’s top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology. PIH Health is certified as a Great Place to Work ^TM.

This position, reporting to the PFS Director, is responsible for the management of clinical denials at both the Whittier and Downey campuses, including timely submission of appeals as required by payer and regulatory requirements, root cause identification, education and training of case managers and physicians on denial prevention techniques, and the implementation of denial prevention workflows and processes across the IDS. In addition, as the team lead this position is responsible for ensuring the following responsibilities are assigned appropriately amongst team members and are completed timely: writing clinical appeals, submitting retro denial reviews, Medi-Cal TARs, and 1-day stay reviews. Lead is also responsible for providing training to staff struggling to meet productivity standards, holding team accountable for completing daily assignments, and escalating issues to the PFS Director, as appropriate.

• Excellent verbal, written, and organizational skills required
• Knowledge of medical terminology and current third party payor reimbursement methodologies
• Ability to follow chain of command
• Ability to support small group of staff, provide training, hold staff accountable for completing daily work
• Self-motivated, proactive, and results oriented
• Must be able to demonstrate sound decision making and prioritization skills, utilizes the approved process to resolve biophysical, psychological, educational and environmental needs of patient/significant others when administering or explaining care.

• Maintain have an active California RN or LVN license.
• Minimum of 3 years acute hospital experience.
• Managed care and case management experience preferred.
• Proficiency with main-frame and personal computers

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