Denial & Appeals Coordinator, RN, Concurrent Denials Prevention

🔥 0 minutes ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $89.5k - $119.1k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

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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

• Function as a senior expert consultant for Case Management • Ensure high-quality patient care, appropriate ALOS, efficient resource utilization, and appropriate medical necessity for expected reimbursement • Evaluate denials and non-certified days from third-party payors for appropriateness and appeal feasibility • Consult with attending physicians, physician advisors, and case managers to formulate secondary and written formal appeals • Use MCG, InterQual, and CMS guidelines for medical necessity determinations • Serve as expert internal consultant to HSS, PFS, Compliance, Surgery, Transfer Center, and other departments on regulatory and billing requirements • Act as liaison between the hospital and eQ Health, CMS, MAC, QIO, ALJ, Medicare Council, and RAC • Prepare appeals for applicable regulatory and review entities • Review all surgery cases across BHSF before and after procedures for appropriate CPT, level of care, relevant testing, authorization, and medical necessity in the EMR prior to billing • Make billing recommendations for medical and surgical accounts based on payor

🎯 Requirements

• Bachelor's degree required, with an exception for RNs hired prior to 2/2012 with an Associate's Degree in Nursing who must complete the BSN within 3 years of hire • RN license and one of the listed certifications required • 4 years minimum required experience • 2 years of hospital or payor Utilization management review experience required • 3 years of hospital clinical experience preferred • 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 • Excellent written, interpersonal communication, and negotiation skills • Strong critical thinking 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 ability to prioritize multiple tasks and role components • Current working knowledge of payor and managed care reimbursement preferred • 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 it within 90 days of hire • Case management, utilization review, or surgery pre-anesthesia experience preferred • Familiarity with CPT, ICD-9, ICD-10, and DRG coding preferred • Strong ability to research evidence-based practices

🏖️ Benefits

• Career growth and development opportunities, with clear pathways and ongoing support • Comprehensive health and wellness resources that go beyond traditional benefits • 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