POSITION SUMMARY:

In this role, the successful candidate will be responsible for the development, direction, and management of the Natera Denials & Appeals Program in support of all business units and products to design and implement solutions to reduce denial root causes, increase appeals success, and improve product revenues and ASPs. This includes the development and oversight of systems that scale to support all business units within Natera (Oncology, Women’s Health, Organ Health) and each of the corresponding products for those BUs. This individual will oversee the development and execution of SOPs for internal teams and external 3rd party vendors to exhaust all available appeals to include both provider and patient authorized avenues in conjunction with support of other internal stakeholders (Billing, Market Access, product marketing, Compliance, etc). This individual will provide oversight and auditing of all functions across all products and regularly communicate strategy, tactics, and performance to senior leadership.

• Serves as a subject matter expert while staying up to date on oncology regulations affecting Denial Prevention and Management practice.
• Provides leadership, training, and direction to internal denial type leads and product focused appeals analysts to reduce administrative denial types through improved operational efficiencies and implements standardized and scalable processes to increase appeal success rate among mature and developing product offerings.

PRIMARY RESPONSIBILITIES:

Develops and implements Standards of Practice for the entire organization supporting all business units and products. Oversees external vendor execution and supports the internal Appeals Specialists teams’ efforts as it relates to formulating and submitting responses to payer denials.

• Manages and prioritizes timely review, investigation and response to payer denials and the required actions for appeals within contractual timeframes.
• Conducts ongoing oversight of the Denials and Appeals Team to analyze adverse determinations, timely review and response to payor denials, and maintenance of department metrics.
  
• Coordinates and collaborates with Content Experts across the enterprise (Physicians, Physician Advisors, Clinical Service Lines, Case Management, Health Information Management, Clinical Documentation Improvement, Inpatient and Outpatient Revenue Services, etc) as needed to obtain necessary documentation to support oncology and genetic appeals and implement prevention.
  
• Assists with the development, maintenance, and management of cases utilizing an internal tracking tool for the distribution of reports as requested by Leadership.
• Identifies, monitors and presents monthly denial performance trends utilizing case studies with recommendations for Process Improvements to the Revenue Cycle Management Team.
  
• Identifies potential risk for lost reimbursement related to medical policies and prior authorization requirements; escalates potential issues to clinical stakeholders, managed care, and revenue cycle leadership, as appropriate.
• Participates in company-wide strategic meetings as needed.
  

QUALIFICATIONS

Bachelor’s degree required.

Master’s in Business Administration or other health related field preferred.

5-7 years of Director Level laboratory focused revenue cycle management experience including 5 years in Claims Denial Management, Appeals Management, or related experience and 3 years of current experience with reimbursement methodologies.

KNOWLEDGE, SKILLS, AND ABILITIES

Strong communication (verbal and written) and interpersonal skills
Ability to communicate with multiple levels of the organization: Senior Leadership, Physicians, Directors, Clinical and Support Staff
Demonstrates strong critical thinking and analytical skills
Ability to work collaboratively in a team environment
Demonstrates the ability to handle multiple assignments and carry out work independently with minimal supervision
Demonstrates responsibility for professional development
Ability to work a flexible schedule to ensure compliance with deadlines
Experience preparing appeals for proprietary CDLTs
Certification in Clinical Documentation Improvement
Qualified candidates must be able to effectively communicate with all levels of the organization.

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