APPEALS COORDINATOR

CalvertHealth; Prince Frederick (MD); On-site; USD 70,000 - 90,000; Full time

Job summary

CalvertHealth is seeking an RN Clinical Appeals Nurse to manage denials and appeals related to medical necessity and level of care. You will serve as a liaison for clinical denial inquiries and coordinate the appeal process with third-party payers and government entities.

In this role, you will review cases against guidelines (MCG/InterQual), determine viability, communicate activities to stakeholders, and help educate clinical teams.

Qualifications

• Bachelor's degree and State Registered Nurse Licensure.
• Minimum 3+ years in Utilization Review and/or Case Management, plus 3 years in a clinical setting.
• Proficiency with office software (Word, Excel, PowerPoint).
• Knowledge of Joint Commission Standards and federal/state documentation requirements for electronic health records.
• Understanding of revenue cycle operations and reimbursement policies.

Responsibilities

• Manage denial/appeal processes for medical necessity and level of care.
• Act as liaison for clinical denials and appeal inquiries with payers and stakeholders.
• Communicate denial/appeal activity and report trends to leadership.
• Coordinate education and performance improvement initiatives to mitigate revenue loss.

Skills

Office software proficiency

Education

Bachelor's degree

RN licensure (State Registered Nurse)

Job description

• Responsible for the management and communication of denials/appeals received from third party payers, managed care companies, and/or government entities related to medical necessity and/or level of care. This associate will be a liaison and point of contact for clinical denials and appeal inquiries. The Appeals Coordinator will review each case identified/referred for appeal based on Milliman Care Guidelines (MCG) or InterQual guidelines, determine the viability of the appeal, and manage the appeal process. The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials. Working with department leaders, this individual will coordinate education and other performance improvement initiatives to mitigate lost revenue related to medical necessity denials. Key Performance and trends related to denials/appeals will be reported to the facility.
• Education:
• Position requires a Bachelor's degree and Registered Nurse Licensure.
• Registration/Certification/Licensure:
• State Registered Nurse Licensure
• Experience:
• Minimum 3+ year's experience in Utilization Review and/or Case Management, and 3 years in a clinical setting.
• Other Requirements:
• Maintains unit-specific and hospital competencies, mandatory learning, and any clinical certifications required in accordance with the Staff Education and Training policy GA-057 and/or any other department requirements.
• Intermediate skill level on the computer: Office Products including Word, Excel, and PowerPoint.
• Demonstrates skills in planning, organizing, and managing multiple functions and complex processes.
• Competent in Joint Commission Standards, Federal and State requirements relating to required documentation for the electronic health record to maintain compliance.
• Knowledge of revenue cycle operations including state and federal reimbursement policies