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

Baptist Health; Orlando (FL); Remote; USD 86,000 - 115,000; Full time

Job summary

An established industry player in healthcare is seeking a Denial & Appeals Coordinator to enhance patient care through effective denial management and appeals processes. This role offers a unique opportunity to work remotely while collaborating with a dedicated team of professionals. You will serve as a vital consultant, ensuring compliance with regulatory guidelines and optimizing resource utilization. With a commitment to compassion and quality, this position allows you to make a meaningful impact on patient outcomes. Join a company recognized for its excellence and become part of a culture that values personal connections and professional growth.

Qualifications

• 3 years of hospital clinical experience preferred.
• 2 years of hospital or payor Utilization management review experience required.
• Strong organizational and time management skills.

Responsibilities

• Evaluate denials and non-certified days from 3rd party payors.
• Consult with physicians to formulate appeals using medical management tools.
• Review surgery cases to ensure proper billing and medical necessity.

Skills

Interpersonal Communication

Critical Thinking

Data Management

Negotiation Skills

Analytical Skills

Education

Bachelor's Degree

Tools

MCG

CPT Coding

ICD-9 & ICD-10 Coding

Excel

Word

Job description

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Baptist Health is the region's largest not-for-profit healthcare organization, with 12 hospitals, over 28,000 employees, 4,500 physicians and 200 outpatient centers, urgent care facilities and physician practices across Miami-Dade, Monroe, Broward and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, Baptist Health is supported by philanthropy and driven by its faith-based mission of medical excellence. For 25 years, we've been named one of Fortune's 100 Best Companies to Work For, and in the 2024-2025 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 45 high-performing honors.

What truly sets us apart is our people. At Baptist Health, we create personal connections with our colleagues that go beyond the workplace, and we form meaningful relationships with patients and their families that extend beyond delivering care. Many of us have walked in our patients' shoes ourselves and that shared experience fuels out commitment to compassion and quality. Our culture is rooted in purpose, and every team member plays a part in making a positive impact - because 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 $86465.60 - $114999.25 / year depending on experience.

Qualifications

Degrees:

• Bachelors.
  
  

Licenses & Certifications:

• AACN Acute/Critical Care Nursing (Adult, Pediatric & Neonatal).
• ANCC Nursing Case Management.
• Registered Nurse.
• AAMCN Utilization Review Professionals.
• ABMCM Certified Managed Care Nurse.
• ACMA Case Management Administrator Certification.
• CCMC Case Manager.
• MCG.
• ACMA ACM Certification.
  
  

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, including disability/vets

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Hospitals and Health Care

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