Denial & Appeals Coordinator, RN, Concurrent Denials Prevention, FT, 08:30A-5P

Baptist 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 excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences.

Baptist Health is supported by philanthropy and committed to its faith-based charitable mission of medical excellence.

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Our mission, vision, and values make us who we are at Baptist Health and are at the center of everything we do. At Baptist Health, we positively impact the human experience for patients, employees, and physicians.

Our success comes from a culture of quality and dedication that is instilled into every member of the Baptist Health family.

This year, and for 24 years, we’ve been named one of Fortune’s 100 Best Companies to Work For, based on employee feedback.

We’ve also been recognized as one of America’s Most Innovative Companies and People Magazine included us in 50 Companies That Care.

Based on the U.S. News & World Report 2023-2024 Best Hospital Rankings, Baptist Health is the most awarded healthcare system in South Florida, with its hospitals and institutes earning 45 high-performing honors.

But really, the reason we’re excited to come to work is the people. Working together, we form personal connections with our colleagues that are stronger than most of us have experienced at other jobs.

We develop caring relationships with our patients and their families that go beyond just delivering healthcare. After all, we know what it’s like to be in their shoes.

Many of us have been patients here and have had family members as patients here. We’re committed to delivering quality care in the most compassionate way possible because we feel a personal stake in the outcomes.

When it comes to caring for people, we’re all in.

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.

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.

Estimated salary range for this position is $85,196.80 - $113,311.74 / year depending on experience.

Qualifications : Degrees : Bachelors

Degrees : Bachelors

Licenses & Certifications :

• AAMCN Utilization Review Professionals
• AACN Acute / Critical Care Nursing (Adult, Pediatric & Neonatal)
• 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 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

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