Denial & Appeals Coordinator, RN – Concurrent Denials Prevention

🔥 1 minute ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $89.5k - $119.1k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Baptist Health

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🤝 Non-profit

Healthcare • Non-profit

Baptist Health is the region's largest not-for-profit healthcare organization in South Florida. It operates 12 hospitals, more than 29,000 employees, 4,500 physicians, and roughly 200 outpatient centers, urgent care facilities, and physician practices across Miami-Dade, Monroe, Broward, and Palm Beach counties. The system includes renowned centers of excellence in cancer, heart and vascular, brain and spine, and orthopedic care, and is supported by philanthropy and a faith-based mission. Baptist Health emphasizes clinical quality, patient safety, staff development, and community-oriented care.

📋 Description

• 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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