Denial & Appeals Coordinator, Remote, RN, Concurrent Denials Prevention

Benefits

At Baptist Health, we’re committed to supporting our employees at every stage of their journey, both personally and professionally. Our approach is rooted in a “grow our own” philosophy, designed to help our team members build meaningful, long‑term careers with us, supported by benefits that make a real difference, including:

• 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
• And so much more

Together, these benefits and others reflect our commitment to caring for our people, so they can build fulfilling careers with us while making a meaningful impact every day.

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 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 $87,755.20 – $ per year depending on experience.

• Degree:
  Bachelor’s
• Licenses &
  
  Certifications:
  
  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;
  Registered Nurse.

• RNs hired prior to 2/2012 with an Associate's 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 3 years of hire.
• RN license and one of the listed certifications is required.
• 3 years of hospital clinical experience preferred and 2 years of hospital or payor utilization management review experience required.
• Excellent written, interpersonal communication and negotiation skills.
• Strong critical thinking skills and the ability to perform clinical chart review and abstract information efficiently.
• Strong analytical, data management and computer skills (Word/Excel).
• Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.
• Current working knowledge of payor and managed care reimbursement preferred.
• Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families.
• Knowledgeable in local, state, and federal legislation and 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 and DRG coding preferred.
• Strong ability to research evidence‑based practices.

Minimum

Required Experience:

4 Years

EOE, including disability/vets