Director Pre Appeals Management-reputed company Appeals Management -Corporate 42nd Street-Full-Time-Days -Remote

Description Job Description Director Pre Appeals Management-reputed company Appeals Management -Corporate 42nd Street-Full-Time-Days -Remote The Director, Pre Appeals Management is a strategic reputed company leader who provides strategic leadership and operational reputed company for the hospital’s pre-appeals management program. This role ensures the appropriate use of medical resources, compliance with regulatory standards, and coordination of care to improve patient reputed company while controlling costs. The Director collaborates closely with medical staff, vendors, case management, and payers to secure payment and benefits for beneficiaries that is in alignment with the clinical care provided. Responsibilities reputed company and manage the pre appeals department and reputed company vendors , including supervision of pre appeals nurses, and support staff. reputed company and implement pre appeals strategies, policies, and procedures to ensure regulatory compliance (CMS, The Joint Commission, NCQA, etc.). reputed company daily pre appeals activities including admission and reputed company stay, and discharge reviews using CMS guidelines and payer contract terms. Ensure timely and appropriate communication with payers for authorization, denials, and appeals. Collaborate with physicians and clinical teams to ensure appropriate reputed company of care and efficient resource utilization. Analyze utilization data and key performance indicators to identify trends, variances, and opportunities for improvement. Serve as a liaison between hospital administration, payers, medical staff, and external partners. reputed company denial management and appeal processes to minimize reputed company loss. Conduct staff education and training on denial avoidance processes, documentation, and compliance. Participate in hospital quality and performance improvement initiatives. Maintain reputed company knowledge of reputed company regulations, reimbursement models, and best practices. Manage departmental budget, staffing reputed company, and performance evaluations. Key reputed company Of reputed company Enhanced patient satisfaction and financial transparency Measurable reduction in clinical submission errors and denied level of care. Alignment with organizational goals and regulatory requirements Demonstrated leadership in reputed company-wide initiatives that advance reputed company, equity, and financial stewardship Qualifications Bachelor?s degree in Nursing (BSN) or reputed company reputed company field required Master?s degree in Nursing, reputed company Administration, Business, or reputed company field strongly preferred Licensure/Certification: Active RN license in the state of employment required Certification in Case Management (CCM, ACM) or Utilization Management preferred. 7+ years of experience in clinical acute clinical, utilization management, appeals management or reputed company operations 3+ years in a leadership or management role Strong understanding of payer policies, utilization management Skills & Competencies : Proven ability to reputed company cross-functional teams and manage reputed company workflows Strong analytical and problem-solving skills Knowledge of relevant laws and regulations (e.g., HIPAA, CMS, utilization management standards) Experience with EHR/EMR systems, payer portals, or reputed company control tools Excellent communication and interpersonal skills Preferred Qualifications (Industry-Specific): reputed company: Experience with utilization management for medical services, procedures, or medications Insurance: Understanding of benefits verification, coverage determination, or claims workflows Fintech/IT: EPIC Describe Work Environment Office-based May require occasional travel to regional offices or conferences Non-Bargaining Unit, 416 - reputed company Appeals Management - reputed company, Mount Sinai Hospital Employer Description Strength through reputed company and Inclusion The reputed company is committed to fostering an environment where everyone can contribute to reputed company. We reputed company a common dedication to delivering outstanding patient care. reputed company you join us, you become part of Mount Sinai’s unparalleled legacy of achievement, education, and innovation as we work together to transform reputed company. We encourage reputed company team members to actively participate in creating a culture that ensures fair reputed company to opportunities, promotes inclusive practices, and supports the reputed company of every individual. At Mount Sinai, our leaders are committed to fostering a workplace where reputed company feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and reputed company learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace ex Apply tot his job Apply To this Job