Coordinator, Appeal & Denials - Care Coordination - Vineland

Inspira Health

About The Position

The Denial and Appeals Coordinator tracks and coordinates third party payer activity and timeliness of organizational response. Identifies, analyzes, and reports denial trends to the department Director, Business Office, Compliance and Managed Care. Maintains monthly reports on internal UM trends including referral volumes and referral outcomes. Participate in Compliance Committee and Denials Committee meetings as appropriate. Serves as a resource to case managers relative to retrospective and concurrent denials and UM processes. Develop educational materials for UM team in conjunction with the Care Coordination Director. Serves as a liaison between case managers, payers, and internal physician advisors in response to payer issues. Collaborates with internal and external stakeholders to ensure compliance to state and national rules and regulations along with payer contracts. Participates in development, review and revision of Care Coordination policies and procedures related to the UM process. Coordinates, tracks and assists with appeals involving the Quality Improvement Organization (QIO). Performs root cause analyses to educate and inform internal process improvement. Maintains clinical competency and current knowledge of regulatory and payor requirements to perform job responsibilities. Point of contact for internal and external teams regarding screening tools (i.e. MCG, Interqual). This position is responsible for providing data-driven insights and reports to leadership, monitoring key metrics related to Utilization Management, and supporting the professional development of the team through mentorship and training.

Requirements

BSN required; MSN preferred.
Registered Nurse licensure required.
Minimum of three years clinical nurse experience.
Minimum of 3 years of utilization review experience required.
Minimum of 2 years recent case management experience required.
Ongoing experience with payer portals and provider manuals as well as CMS regulations.
Registered Nurse License Required
Demonstrates role-modeling behavior through professional and effective interpersonal communication with staff and external stakeholders.
Must have knowledge and understanding of Centers for Medicare &Medicaid Services (CMS) guidelines and Conditions of Participation.
Ability to work independently and set priorities efficiently under constraints of managed care guidelines.
Ability to coordinate, compile, and analyze data. Maintain denial tracker and UM report (LOS, denial rate, turn around times, UM outliers)
Excellent communication skills (oral and written) and interpersonal skills necessary to negotiate with families, patients, post-acute providers and third- party payors.
Understanding of payer portals and provider manuals

Responsibilities

Tracks and coordinates third party payer activity and timeliness of organizational response.
Identifies, analyzes, and reports denial trends to the department Director, Business Office, Compliance and Managed Care.
Maintains monthly reports on internal UM trends including referral volumes and referral outcomes.
Participates in Compliance Committee and Denials Committee meetings as appropriate.
Serves as a resource to case managers relative to retrospective and concurrent denials and UM processes.
Develops educational materials for UM team in conjunction with the Care Coordination Director.
Serves as a liaison between case managers, payers, and internal physician advisors in response to payer issues.
Collaborates with internal and external stakeholders to ensure compliance to state and national rules and regulations along with payer contracts.
Participates in development, review and revision of Care Coordination policies and procedures related to the UM process.
Coordinates, tracks and assists with appeals involving the Quality Improvement Organization (QIO).
Performs root cause analyses to educate and inform internal process improvement.
Maintains clinical competency and current knowledge of regulatory and payor requirements to perform job responsibilities.
Point of contact for internal and external teams regarding screening tools (i.e. MCG, Interqual).
Provides data-driven insights and reports to leadership
Monitors key metrics related to Utilization Management
Supports the professional development of the team through mentorship and training.