Denial & Appeals Coordinator, RN – Concurrent Denials Prevention

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

📋 Description

• Acts as a senior expert consultant in Case Management to guarantee high-quality patient care, suitable ALOS, efficient resource use, and correct application of regulatory and national guidelines.

• Assesses denials and non-certified days from third-party payors to evaluate the appropriateness of the denial and the feasibility of an appeal.

• Collaborates with attending physicians, physician advisors, and case managers to develop secondary and formal written appeals utilizing MCG, InterQual, and CMS guidelines.

• Functions as an expert internal consultant for HSS, PFS, Compliance, Surgery, Transfer Center, and other departments regarding regulatory and billing requirements, including LCD/NCD/EBC criteria.

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

• Prepares appeals for relevant regulatory and payer entities.

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

• Provides billing recommendations for medical and surgical accounts based on payer guidelines.

⛳️ Requirements

• Bachelor's degree.

• RN license along with one of the specified certifications is mandatory.

• Minimum of 4 years of required experience.

• A minimum of 2 years of experience in hospital or payor Utilization management review is essential.

• RNs employed before 2/2012 with an Associate's Degree in Nursing must achieve a BSN within 3 years of hire.

• Exceptional written, interpersonal communication, and negotiation skills.

• Strong critical thinking abilities and proficiency in conducting clinical chart reviews and abstracting information efficiently.

• Proficient analytical, data management, and computer skills, particularly in Word and Excel.

• Excellent organizational and time management capabilities, with the ability to prioritize multiple tasks and responsibilities.

• Capacity to work independently and exercise sound judgment in interactions with the healthcare team and patients/families.

• Understanding of local, state, and federal legislation and regulations.

• Ability to meet high-volume production standards.

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

• Strong aptitude for researching evidence-based practices.

• Preferably 3 years of hospital clinical experience.

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

• Experience in case management and utilization review/surgery pre-anesthesia is preferred.

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

• One of the following certifications is required: 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

• Opportunities for career growth and development, with clear pathways and continuous support.

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

• A wellness program designed to assist employees in eliminating their medical plan deductible, thereby reducing out-of-pocket healthcare expenses.

• Tuition reimbursement available to promote ongoing learning and advancement.