Denial & Appeals Coordinator, Remote, RN, Concurrent Denials Prevention, FT, 08:30A-5P

About the role

This position serves as a senior expert consultant for Case Management at Baptist Health to ensure high quality patient care, appropriate ALOS, efficient resource utilization, and adherence to regulatory and national guidelines.

Responsibilities

• Evaluates denials and non-certified days from third-party payors to determine appropriateness of denial and feasibility of appeal.
• Consults with attending physician, physician advisor, and case managers to formulate secondary appeals and written formal appeals using appropriate medical management tools for medical necessity determination (MCG/Interqual/CMS guidelines).
• Serves as the expert internal consultant for multiple departments (HSS, PFS, Compliance, Surgery, Transfer Center, etc.) related to regulatory and billing requirements (LCD/NCD/EBC criteria).
• Serves as liaison between hospital and eQ health, CMS, and when appropriate their Contractors such as the MAC, QIO, ALJ, Medicare Council, and the RAC, preparing appeals for all of the above.
• Reviews all surgery cases across BHSF pre and post-procedure to ensure appropriate CPT, LOB, relevant testing, authorization, and medical necessity are present in the EMR prior to billing.
• Makes billing recommendations for all medical and surgical accounts as applicable by payor.

Qualifications

• Education: Bachelors.
• Licenses & Certifications: AAMCN, Utilization Review Professional, AACN, ACMA, CCMC, ANCC, Registered Nurse.
• Additional Qualifications: RNs with an Associates Degree in Nursing are not required to have a BSN but must complete the BSN within 3 years of hire. 3 years of hospital clinical experience preferred and 2 years of hospital or payor Utilization management review experience required. Excellent written, interpersonal communication & negotiation skills, strong critical thinking skills, strong analytical, data management & computer skills, strong organizational & time management skills, current working knowledge of payor & managed care reimbursement, ability to work independently & exercise sound judgment, knowledge of local, state, & federal legislation & regulations, ability to tolerate high volume production standards, MCG Certification or eligible to pursue within 90 days of hire, Case management, utilization review/surgery pre-anesthesia experience preferred, familiarity with CPT, ICD-9 &-10 & DRG coding, strong ability to research evidence-based practices.
• Minimum Required Experience: 4 Years.

Pay

The estimated salary range for this position is $87,755.20 - $116,714.42 per year depending on experience.