Denial & Appeals Coordinator, RN, Concurrent Denials Prevention, FT, 08:30A-5P
1 month ago
Baptist 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.
A not-for-profit organization supported by philanthropy and committed to its faith-based charitable mission of medical excellence, Baptist Health has been recognized by Fortune as one of the 100 Best Companies to Work For in America and by Ethisphere as one of the World's Most Ethical Companies.
Everything we do at Baptist Health, we do to the best of our ability. That includes supporting our team with extensive training programs, millions of dollars in tuition assistance, comprehensive benefits and more. Working within our award-winning culture means getting the respect and support you need to do your best work ever. Find out why we're all in for helping you be your best.Description:
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.
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
Qualifications:
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
EOE
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Coral Gables, Florida, United States Baptist Health South Florida Full timeDescription: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...
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Coral Gables, Florida, United States Baptist Health South Florida Full timeDescription: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...
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Coral Gables, 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...
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Pool Denial
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Coral Gables, 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...
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Coral Gables, 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...
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Coral Gables, 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...
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Coral Gables, 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...
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Coral Gables, 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...
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Coral Gables, 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...
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Coral Gables, 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...
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Coral Gables, 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...
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Coral Gables, 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...
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Coral Gables, 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...
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Coral Gables, 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...
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Coral Gables, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is once again one of the 2019 Fortune 100 Best Companies to Work For This is the 19th time Baptist Health has been named to the prestigious list and is the only healthcare provider in the state to be ranked. We have also been recognized for being among the best healthcare providers in the nation by U.S. News & World Reports in...
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Coral Gables, Florida, United States Baptist Health South Florida Full timeBaptist Health South Florida is once again one of the 2019 Fortune 100 Best Companies to Work For This is the 19th time Baptist Health has been named to the prestigious list and is the only healthcare provider in the state to be ranked. We have also been recognized for being among the best healthcare providers in the nation by U.S. News & World Reports in...
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Coral Gables, 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...
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Coral Gables, 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...
-
Coral Gables, 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...
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Coral Gables, 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...
