The ADR and Appeals Manager is responsible for the oversight and management of all aspects of the Additional Documentation Request (ADR) and appeals process for Ciena Healthcare. This individual ensures compliance with Medicare, Medicaid, and other third-party payer requirements, while working collaboratively with clinical, billing, and legal teams to support timely, accurate, and defensible responses to audits, denials, and appeals.

Join us with an attractive benefits offering:

• Competitive pay
• Medical, dental, and vision insurance
• 401K with matching funds
• Life Insurance
• Employee discounts
• Tuition Reimbursement
• Student Loan Reimbursement

Responsibilities:

ADR Management:

• Receive, log, and track all ADRs from payers (Medicare, Medicaid, private insurers).
• Coordinate with 3rd party vendor the collection and submission of required documentation within specified deadlines.
• Ensure documentation accuracy, completeness, and compliance with payer requirements.
• Maintain organized and secure records of all ADRs and responses.

Appeals Coordination:

• Manage and oversee the entire appeals process from initial denial through final resolution. Draft, review, and submit appeals, including reconsideration and administrative law judge (ALJ) levels as necessary.
• Collaborate with legal counsel and external consultants on complex cases as needed.
• Conduct root cause analysis of denials to identify patterns and prevent future occurrences.

Communication & Collaboration:

• Liaise with facility staff, therapy providers, billing teams, and medical records departments to gather necessary documentation.
• Serve as the point of contact for auditors and external reviewers.
• Communicate updates and outcomes to leadership and relevant stakeholders.

Education & Compliance:

• Train facility and regional teams on documentation best practices to reduce denial rates.
• Keep current with regulatory and payer changes affecting ADR and appeals processes.
• Develop and update internal policies and procedures related to ADRs and appeals.

Reporting & Metrics:

• Maintain tracking systems to monitor ADR and appeal status, volumes, and outcomes.
• Generate regular reports for senior leadership detailing trends, risks, and opportunities for improvement.

Requirements:

• Bachelor's degree preferred in health information management, Nursing, Healthcare Administration, or related field required. RHIA, RHIT, RN, or equivalent preferred.
• Minimum of 3-5 years of experience in healthcare reimbursement, appeals, or compliance, preferably in the skilled nursing or long-term care sector.
• Strong knowledge of MDS 3.0, PDPM, Medicare/Medicaid regulations, audit procedures, and appeal rights.
• Ability to manage multiple deadlines and coordinate cross-functional teams.
• Proficiency in Microsoft Office Suite and experience with EHR and billing systems.
• Familiarity with MACs, RACs, UPICs, and ZPICs.
• Ability to travel as needed.

Ciena Healthcare
We are a national organization of skilled nursing, subacute, rehabilitative, and assisted living providers dedicated to achieving the highest standards of care in five states including Michigan, Ohio, Virginia, North Carolina, and Indiana.

We serve our residents with compassion, concern, and excellence, believing that every one of them is a unique person who deserves our best each day that we care for them. Join us, if you have a passion for improving the lives of those around you and working with others who feel the same way.

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