Denial & Appeals Coordinator, RN, Concurrent Denials Prevention, FT, 08:30A-5P

Baptist Health South Florida • FL

93d • $87,755 - $116,714

About The Position

Functions as a senior expert consultant for Case Management to ensure high quality patient care, appropriate ALOS, efficient resource utilization, application of regulatory and national guidelines to ensure medical necessity is appropriate for expected reimbursement. Evaluates denials and non-certified days from 3rd party payors to determine appropriateness of denial and feasibility of appeal. Consults with attending physician, physician advisor, and case managers to formulate secondary appeals and written formal appeals using appropriate medical management tools for medical necessity determination (MCG/Interqual/ CMS guidelines). Serves as the expert internal consultant for multiple departments (HSS, PFS, Compliance, Surgery, Transfer Center, etc.) related to regulatory and billing requirements (LCD/NCD/EBC criteria). Serves as liaison between hospital and eQ health, CMS and when appropriate their Contractors such as the MAC, QIO, ALJ, Medicare Council, and the RAC and prepares appeals for all of the above. Reviews all surgery cases across BHSF pre and post procedure to ensure appropriate CPT, LOC, Relevant testing, authorization and medical necessity is present in the EMR prior to billing. Makes billing recommendation for all medical and surgical accounts as applicable by payor.

Requirements

• Bachelor's degree.
• Registered Nurse license.
• AAMCN Utilization Review Professionals certification.
• AACN Acute/Critical Care Nursing certification.
• MCG certification.
• ABMCM Certified Managed Care Nurse certification.
• ACMA Case Management Administrator Certification.
• CCMC Case Manager certification.
• ACMA ACM Certification.
• ANCC Nursing Case Management certification.
• 3 years of hospital clinical experience preferred.
• 2 years of hospital or payor Utilization management review experience required.
• Excellent written, interpersonal communication & negotiation skills.
• Strong critical thinking skills.
• Strong analytical, data management & computer skills (Word/Excel).
• Strong organizational & time management skills.
• Current working knowledge of payor & managed care reimbursement preferred.
• Ability to work independently & exercise sound judgment.
• Knowledgeable in local, state, & federal legislation & regulations.
• Ability to tolerate high volume production standards.
• MCG Certification or eligible to pursue within 90 days of hire.
• Familiar with CPT, ICD-9 &-10 & DRG coding preferred.
• Strong ability to research evidence-based practices.

Nice To Haves

• Case management, utilization review/surgery pre-anesthesia experience preferred.

Responsibilities

• Ensure high quality patient care and appropriate ALOS.
• Evaluate denials and non-certified days from 3rd party payors.
• Consult with attending physician, physician advisor, and case managers for appeals.
• Serve as expert internal consultant for multiple departments regarding regulatory and billing requirements.
• Liaise between hospital and eQ health, CMS, and their contractors.
• Prepare appeals for various entities including MAC, QIO, ALJ, Medicare Council, and RAC.
• Review all surgery cases pre and post procedure for billing accuracy.
• Make billing recommendations for medical and surgical accounts.

Benefits

• Estimated salary range for this position is $87,755.20 - $116,714.42 / year depending on experience.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees