APPEALS COORDINATOR

Job Summary

Responsible for the management and communication of denials/appeals received from third party payers, managed care companies, and/or government entities related to medical necessity and/or level of care. This associate will be a liaison and point of contact for clinical denials and appeal inquiries. The Appeals Coordinator will review each case identified/referred for appeal based on Milliman Care Guidelines (MCG) or InterQual guidelines, determine the viability of the appeal, and manage the appeal process. The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials. Working with department leaders, this individual will coordinate education and other performance improvement initiatives to mitigate lost revenue related to medical necessity denials. Key Performance and trends related to denials/appeals will be reported to the facility.

Education

Position requires a Bachelor's degree and Registered Nurse Licensure.

Experience

• Minimum 3+ years' experience in Utilization Review and/or Case Management, and 3 years in a clinical setting.

Other Requirements

• Maintains unit-specific and hospital competencies, mandatory learning, and any clinical certifications required in accordance with the Staff Education and Training policy GA-057 and/or any other department requirements.
• Intermediate skill level on the computer: Office Products including Word, Excel, and PowerPoint.
• Demonstrates skills in planning, organizing, and managing multiple functions and complex processes.
• Competent in Joint Commission Standards, Federal and State requirements relating to required documentation for the electronic health record to maintain compliance.
• Knowledge of revenue cycle operations including state and federal reimbursement policies.