Denial & Appeals Coordinator, RN, Concurrent Denials Prevention

This is a fully remote position, open to applicants in Florida.

📋 Description

• Serve as a senior consultant specializing in Case Management.

• Ensure the delivery of high-quality patient care, appropriate Average Length of Stay (ALOS), efficient resource utilization, and medical necessity for anticipated reimbursement.

• Assess denial cases and non-certified days from third-party payors for appropriateness and the feasibility of appealing.

• Collaborate with attending physicians, physician advisors, and case managers to develop secondary and formal written appeals.

• Apply MCG, InterQual, and CMS guidelines for determining medical necessity.

• Act as an expert internal consultant for HSS, PFS, Compliance, Surgery, Transfer Center, and other departments regarding regulatory and billing requirements.

• Function as a liaison between the hospital and eQ Health, CMS, MAC, QIO, ALJ, Medicare Council, and RAC.

• Prepare appeals for relevant regulatory and review entities.

• Examine all surgical cases across BHSF before and after procedures for appropriate CPT codes, level of care, relevant testing, authorization, and medical necessity in the EMR prior to billing.

• Provide billing recommendations for medical and surgical accounts based on payor.

⛳️ Requirements

• A Bachelor's degree is mandatory, with an exception for RNs hired before 2/2012 who possess an Associate's Degree in Nursing and must complete the BSN within 3 years of employment.

• An active RN license and one of the specified certifications are required.

• A minimum of 4 years of relevant experience is required.

• At least 2 years of experience in hospital or payor Utilization management review is essential.

• 3 years of clinical experience in a hospital setting is preferred.

• Certifications such as ACMA ACM Certification, CCMC Case Manager, AACN Acute/Critical Care Nursing, ABMCM Certified Managed Care Nurse, AAMCN Utilization Review Professionals, MCG, ANCC Nursing Case Management, or ACMA Case Management Administrator Certification are desired.

• Exceptional written, interpersonal communication, and negotiation abilities are essential.

• Strong critical thinking skills and the capability to efficiently perform clinical chart reviews and abstract information are required.

• Excellent analytical, data management, and computer skills, particularly in Word and Excel, are necessary.

• Strong organizational and time management skills, with the ability to prioritize multiple tasks and responsibilities.

• Current knowledge of payor and managed care reimbursement is preferred.

• Capability to work independently and demonstrate sound judgment in interactions with healthcare teams and patients/families.

• Familiarity with local, state, and federal legislation and regulations is important.

• Ability to maintain high-volume production standards is necessary.

• MCG Certification or eligibility to pursue it within 90 days of hire is required.

• Experience in case management, utilization review, or surgery pre-anesthesia is preferred.

• Familiarity with CPT, ICD-9, ICD-10, and DRG coding is preferred.

• A strong ability to research evidence-based practices is essential.

🏝️ Benefits

• Opportunities for career growth and development, featuring clear pathways and ongoing support.

• Comprehensive health and wellness resources that extend beyond traditional benefits.

• A wellness program designed to help employees eliminate their medical plan deductible, thus reducing out-of-pocket healthcare expenses.

• Tuition reimbursement to assist with ongoing education and career advancement.