Denial & Appeals Coordinator, RN, Concurrent Denials Prevention, FT, 08:30A-5P
2 weeks ago
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 payorEstimated salary range for this position is $ $ / year depending on experience.
Degrees:
Bachelors
Licenses & Certifications:
AAMCN Utilization Review Professionals
AACN Acute/Critical Care Nursing (Adult, Pediatric & Neonatal)
MCG
ABMCM Certified Managed Care Nurse
CCMC Case Manager
ACMA ACM Certification
Registered Nurse
ANCC Nursing Case Management
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 st&ards.
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
-
Miami, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is the region's largest not-for-profit healthcare organization with 12 hospitals, more than 27,000 employees, 4,000 physicians, and 200 outpatient centers, urgent care facilities, and physician practices spanning across Miami-Dade, Monroe, Broward, and Palm Beach counties. Baptist Health has internationally renowned centers of...
-
RN Case Manager
4 weeks ago
Miami, Florida, United States Nicklaus Children's Health System Full timeJob SummaryPlans, assesses, re-assess, implements, monitors, and evaluates the options and services required to meet the healthcare needs of the patients using the functions of Utilization Resource Management, Transition of Care, Discharge Planning, and Case Management in order to facilitate: (1) quality of patient care; (2) cost effective utilization and...
-
RN Case Manager
1 month ago
Miami, Florida, United States Nicklaus Children's Health System Full timeJob SummaryPlans, assesses, re-assess, implements, monitors, and evaluates the options and services required to meet the healthcare needs of the patients using the functions of Utilization Resource Management, Transition of Care, Discharge Planning, and Case Management in order to facilitate: (1) quality of patient care; (2) cost effective utilization and...
-
Miami, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is the largest healthcare organization in the region, with 12 hospitals, more than 24,000 employees, 4,000 physicians and 100 outpatient centers, urgent care facilities and physician practices spanning across Miami-Dade, Monroe, Broward and Palm Beach counties. Baptist Health has internationally renowned centers of excellence in...
-
Miami, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is the largest healthcare organization in the region, with 12 hospitals, more than 24,000 employees, 4,000 physicians and 100 outpatient centers, urgent care facilities and physician practices spanning across Miami-Dade, Monroe, Broward and Palm Beach counties. Baptist Health has internationally renowned centers of excellence in...
-
RN Case Manager
1 month ago
Miami, Florida, United States Nicklaus Children's Hospital Full timeDescriptionJob SummaryPlans, assesses, re-assess, implements, monitors, and evaluates the options and services required to meet the healthcare needs of the patients using the functions of Utilization Resource Management, Transition of Care, Discharge Planning, and Case Management in order to facilitate: (1) quality of patient care; (2) cost effective...
-
Miami, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is the largest healthcare organization in the region, with 12 hospitals, more than 24,000 employees, 4,000 physicians and 100 outpatient centers, urgent care facilities and physician practices spanning across Miami-Dade, Monroe, Broward and Palm Beach counties. Baptist Health has internationally renowned centers of excellence in...
-
Miami, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is the largest healthcare organization in the region, with 12 hospitals, more than 24,000 employees, 4,000 physicians and 100 outpatient centers, urgent care facilities and physician practices spanning across Miami-Dade, Monroe, Broward and Palm Beach counties. Baptist Health has internationally renowned centers of excellence in...
-
Miami, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is the region's largest not-for-profit healthcare organization with 12 hospitals, more than 27,000 employees, 4,000 physicians, and 200 outpatient centers, urgent care facilities, and physician practices spanning across Miami-Dade, Monroe, Broward, and Palm Beach counties. Baptist Health has internationally renowned centers of...
-
Miami, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is the region's largest not-for-profit healthcare organization with 12 hospitals, more than 27,000 employees, 4,000 physicians, and 200 outpatient centers, urgent care facilities, and physician practices spanning across Miami-Dade, Monroe, Broward, and Palm Beach counties. Baptist Health has internationally renowned centers of...
-
Miami, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is the largest healthcare organization in the region, with 12 hospitals, more than 27,000 employees, 4,000 physicians and 100 outpatient centers, urgent care facilities and physician practices spanning across Miami-Dade, Monroe, Broward and Palm Beach counties. Baptist Health has internationally renowned centers of excellence in...
-
Miami, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is the largest healthcare organization in the region, with 12 hospitals, more than 27,000 employees, 4,000 physicians and 100 outpatient centers, urgent care facilities and physician practices spanning across Miami-Dade, Monroe, Broward and Palm Beach counties. Baptist Health has internationally renowned centers of excellence in...
-
Miami, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is the region's largest not-for-profit healthcare organization with 12 hospitals, more than 27,000 employees, 4,000 physicians, and 200 outpatient centers, urgent care facilities, and physician practices spanning across Miami-Dade, Monroe, Broward, and Palm Beach counties. Baptist Health has internationally renowned centers of...
-
Miami, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is the region's largest not-for-profit healthcare organization with 12 hospitals, more than 27,000 employees, 4,000 physicians, and 200 outpatient centers, urgent care facilities, and physician practices spanning across Miami-Dade, Monroe, Broward, and Palm Beach counties. Baptist Health has internationally renowned centers of...
-
Miami, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is the region's largest not-for-profit healthcare organization with 12 hospitals, more than 27,000 employees, 4,000 physicians, and 200 outpatient centers, urgent care facilities, and physician practices spanning across Miami-Dade, Monroe, Broward, and Palm Beach counties. Baptist Health has internationally renowned centers of...
-
Miami, Florida, United States UOMUOMUS Full timeCurrent Employees:If you are a current Staff, Faculty or Temporary employee at the University of Miami, please click here to log in to Workday to use the internal application process. To learn how to apply for a faculty or staff position using the Career worklet, please review this tip sheet.The University of Miami is currently seeking Utilization Review...
-
Miami, Florida, United States UOMUOMUS Full timeCurrent Employees:If you are a current Staff, Faculty or Temporary employee at the University of Miami, please click here to log in to Workday to use the internal application process. To learn how to apply for a faculty or staff position using the Career worklet, please review this tip sheet.The University of Miami is currently seeking Utilization Review...
-
Miami, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is the largest healthcare organization in the region, with 12 hospitals, more than 24,000 employees, 4,000 physicians and 100 outpatient centers, urgent care facilities and physician practices spanning across Miami-Dade, Monroe, Broward and Palm Beach counties. Baptist Health has internationally renowned centers of excellence in...
-
Miami, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is the largest healthcare organization in the region, with 12 hospitals, more than 24,000 employees, 4,000 physicians and 100 outpatient centers, urgent care facilities and physician practices spanning across Miami-Dade, Monroe, Broward and Palm Beach counties. Baptist Health has internationally renowned centers of excellence in...
-
Miami, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is the largest healthcare organization in the region, with 12 hospitals, more than 24,000 employees, 4,000 physicians and 100 outpatient centers, urgent care facilities and physician practices spanning across Miami-Dade, Monroe, Broward and Palm Beach counties. Baptist Health has internationally renowned centers of excellence in...
