Senior Clinical Denials Coordinator

Mount Sinai Medical Center • Miami Beach, FL

2d • Onsite

About The Position

The Sr. Clinical Denials Coordinator serves as a Clinical Denials Unit Reviewer responsible for managing and appealing level-of-care and medical necessity denials. This role applies clinical judgment, payer policy knowledge, InterQual criteria, and contract language to construct high-quality appeals and optimize reimbursement outcomes. Conducts clinical appeals for level of care medical necessity denials.

Requirements

• RN License preferred.
• Medical School Graduate/Bachelor's Degree required.
• Critical Care/ Surgery/ Intensive Care patient care experience or two years prior experience in case management, clinical denials appeals/ utilization management or related field.

Responsibilities

• Communicates effectively with Business Office and Care Management teams in order to draw all necessary information and assess best course of action.
• Has command of InterQual criteria and can navigate application efficiently.
• Is familiar with contracts and can discern what contract language means, which language clauses are relevant to her reviews and correctly applies these into her appeals and/or conclusions.
• Constructs well-redacted, concise and eloquent appeals, with rationales that are supported with as much clinical data/evidence as possible.
• Has appropriate command of clinical concepts and is competent performing clinical chart reviews.
• Periodically follows up on cases, appeals pending decisions, and updates data within reporting tool accurately and in a timely basis.
• Escalates unfavorable cases that may need Peer-to-peer review and ensures all appeal options are exhausted.
• Maintains productivity rate of 5-10 daily appeals or as otherwise agreed with management.
• Familiar navigating all necessary applications to complete duties including Epic Hospital Billing, Epic Doc Review, MoreCare, OneContent, InterQual, Availity, Optum, other payor portals, etc.
• Is familiar with Payor's policies and appeals process and ensures appeals are completed timely.
• Maintains reporting tool that can effectively track program's outcomes.
• Identifies trends and reports to management, including recommendations for corrective action.
• All other tasks as assigned.

Benefits

• Health benefits
• Life insurance
• Long-term disability coverage
• Healthcare spending accounts
• Retirement plan
• Paid time off
• Pet Insurance
• Tuition reimbursement
• Employee assistance program
• Wellness program
• On-site housing for select positions

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Number of Employees: 501-1,000 employees