Denial & Appeals Coordinator, RN – Concurrent Denials Prevention
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Job Description
Remote RN coordinator evaluating hospital denials, medical necessity, and appeals. Supporting Baptist Health’s South Florida healthcare system with utilization and billing recommendations.
Responsibilities:
- Functions as a senior expert consultant for Case Management to ensure high quality patient care, appropriate ALOS, efficient resource utilization, and appropriate application of regulatory and national guidelines
- Evaluates denials and non-certified days from third-party payors to determine appropriateness of denial and feasibility of appeal
- Consults with attending physicians, physician advisors, and case managers to formulate secondary and formal written appeals using MCG, InterQual, and CMS guidelines
- Serves as expert internal consultant for HSS, PFS, Compliance, Surgery, Transfer Center, and other departments regarding regulatory and billing requirements, including LCD/NCD/EBC criteria
- Serves as liaison between the hospital and eQ health, CMS, MAC, QIO, ALJ, Medicare Council, and RAC
- Prepares appeals for applicable regulatory and payer entities
- Reviews all surgery cases across BHSF before and after procedures to ensure appropriate CPT, level of care, relevant testing, authorization, and medical necessity are documented in the EMR before billing
- Makes billing recommendations for medical and surgical accounts according to payer
Requirements:
- Bachelor's degree
- RN license and one of the listed certifications is required
- 4 years minimum required experience
- 2 years of hospital or payor Utilization management review experience required
- RNs hired prior to 2/2012 with an Associates Degree in Nursing must complete the BSN within 3 years of hire
- Excellent written, interpersonal communication and negotiation skills
- Strong critical thinking skills and ability to perform clinical chart review and abstract information efficiently
- Strong analytical, data management and computer skills, including Word and Excel
- Strong organizational and time management skills, with capacity to prioritize multiple tasks and role components
- Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families
- Knowledge of local, state, and federal legislation and regulations
- Ability to tolerate high volume production standards
- MCG Certification or eligibility to pursue within 90 days of hire
- Strong ability to research evidence-based practices
- 3 years of hospital clinical experience preferred
- Current working knowledge of payor and managed care reimbursement preferred
- Case management, utilization review/surgery pre-anesthesia experience preferred
- Familiarity with CPT, ICD-9 and ICD-10, and DRG coding preferred
- One of the listed certifications: ACMA ACM Certification; CCMC Case Manager; AACN Acute/Critical Care Nursing (Adult, Pediatric & Neonatal); ABMCM Certified Managed Care Nurse; AAMCN Utilization Review Professionals; MCG; ANCC Nursing Case Management; ACMA Case Management Administrator Certification
Benefits:
- Career growth and development opportunities, with clear pathways and ongoing support
- Comprehensive health and wellness resources that go beyond traditional benefits
- A wellness program that can help employees eliminate their medical plan deductible, reducing out-of-pocket healthcare costs
- Tuition reimbursement to support continued learning and advancement
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