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

Baptist Health

279d • $86,465 - $114,999 • Remote

About The Position

The Denial & Appeals Coordinator, RN, Concurrent Denials Prevention position at Baptist Health South Florida functions as a senior expert consultant for Case Management. The role ensures high-quality patient care, appropriate average length of stay (ALOS), and efficient resource utilization while applying regulatory and national guidelines to ensure medical necessity is appropriate for expected reimbursement. The coordinator evaluates denials and non-certified days from third-party payors to determine the appropriateness of denial and feasibility of appeal. They consult with attending physicians, physician advisors, and case managers to formulate secondary appeals and written formal appeals using appropriate medical management tools for medical necessity determination. The coordinator serves as the expert internal consultant for multiple departments related to regulatory and billing requirements and acts as a liaison between the hospital and various health organizations, preparing appeals as necessary. Additionally, they review all surgery cases across Baptist Health South Florida pre and post-procedure to ensure appropriate coding, authorization, and medical necessity is present in the electronic medical record prior to billing.

Requirements

• Bachelor's degree required.
• Registered Nurse license required.
• 3 years of hospital clinical experience preferred.
• 2 years of hospital or payor Utilization management review experience required.
• Excellent written and interpersonal communication skills.
• Strong critical thinking and analytical skills.
• Current working knowledge of payor and managed care reimbursement preferred.
• Ability to work independently and exercise sound judgment.

Nice To Haves

• MCG Certification or eligible to pursue within 90 days of hire.
• Case management and utilization review/surgery pre-anesthesia experience preferred.
• Familiarity with CPT, ICD-9 &-10, and DRG coding preferred.

Responsibilities

• Ensure high-quality patient care and appropriate ALOS.
• Evaluate denials and non-certified days from third-party payors.
• Consult with attending physicians and case managers to formulate appeals.
• Serve as an expert internal consultant for multiple departments.
• Act as a liaison between the hospital and health organizations.
• Review all surgery cases to ensure appropriate coding and medical necessity.
• Make billing recommendations for medical and surgical accounts.

Benefits

• Competitive salary range of $86,465.60 - $114,999.25 per year depending on experience.
• Opportunities for professional development and continuing education.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Hospitals
• Education Level: Bachelor's degree