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Denial & Appeals Coordinator, Remote, RN, Concurrent Denials Prevention, FT, 08:30A-5P
About the position
Functions as a senior expert consultant for Case Management to ensure high quality patient care, appropriate ALOS, efficient resource utilization, application of regulatory and national guidelines to ensure medical necessity is appropriate for expected reimbursement. Evaluates denials and non-certified days from 3rd 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.
Responsibilities
- Evaluate denials and non-certified days from 3rd party payors to determine appropriateness of denial and feasibility of appeal.
- Consult 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).
- Serve 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).
- Serve 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.
- Review 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.
- Make billing recommendations for all medical and surgical accounts as applicable by payor.
Requirements
- RN license & one of the listed certifications is required.
- 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.
- 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 st&ards.
- MCG Certification or eligible to pursue within 90 days of hire.
- Minimum Required Experience: 4 Years
Nice-to-haves
- AAMCN Utilization Review Professionals.
- AACN Acute/Critical Care Nursing (Adult, Pediatric & Neonatal).
- MCG.
- ABMCM Certified Managed Care Nurse.
- ACMA Case Management Administrator Certification.
- CCMC Case Manager.
- ACMA ACM Certification.
- ANCC Nursing Case Management.
- 3 years of hospital clinical experience preferred.
- Current working knowledge of payor & managed care reimbursement preferred.
- 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.
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
