Denial & Appeals Coordinator, RN, Concurrent Denials Prevention, FT, 08A-4:30P

Job Title

Functions as a senior expert consultant for Case Management to ensure high quality patient care, appropriate ALOS, efficient resource utilization, and application of regulatory and national guidelines to ensure medical necessity is appropriate for expected reimbursement. 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 and prepares appeals for all of the above. Reviews all surgery cases across BHSF pre and post procedure to ensure appropriate CPT, LOC, relevant testing, authorization, and medical necessity is present in the EMR prior to billing. Makes billing recommendation for all medical and surgical accounts as applicable by payor.

Estimated salary range for this position is $86465.60 - $114999.25 / year depending on experience.

Qualifications:

Degrees:

• Bachelors.

Licenses & Certifications:

• 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.
• Registered Nurse.
• ACMA ACM Certification.
• ACMA Case Management Administrator Certification.

Additional Qualifications:

• RNs hired prior to 2/2012 with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN, however, they are required to complete the BSN within 5 years of hire.
• RN license & one of the listed certifications is required.
• 3 years of hospital clinical experience preferred & 2 years of hospital or payor Utilization management review experience required.
• Excellent written, interpersonal communication & negotiation skills.
• Strong critical thinking skills & the ability to perform clinical chart review abstract information efficiently.
• Strong analytical, data management & computer skills/Word /Excel.
• Strong organizational & time management skills, as evidenced by capacity to prioritize multiple tasks & role components.
• Current working knowledge of payor & managed care reimbursement preferred.
• Ability to work independently & exercise sound judgment in interactions with the health care team & patients/families.
• Knowledgeable in 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.
• Familiar with CPT, ICD-9 &-10 & DRG coding preferred.
• Strong ability to research evidence-based practices.

Minimum Required Experience: 3

EOE, including disability/vets