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

Baptist Health; United States; On-site; USD 90,000 - 119,000; Full time

Benefits offered by this job

Career growth opportunities

Health and wellness resources

Tuition reimbursement

Job summary

Baptist Health is seeking a senior expert consultant for Case Management to ensure high quality patient care, appropriate length of stay, efficient resource use, and adherence to regulatory guidelines. The role analyzes denials and coordinates appeals with physicians and payors to secure appropriate reimbursement.

The position requires RN licensure with various certifications, strong analytical and communication skills, and experience in utilization management and hospital operations.

Qualifications

• Minimum Required Experience: 4 Years
• RN license is required
• BSN must be obtained within 3 years of hire

Responsibilities

• Functions as a senior expert consultant for Case Management to ensure high quality patient care and appropriate ALOS.
• Evaluate denials and non-certified days from 3rd party payors to determine appropriateness of denial and feasibility of appeal.
• Consult with attending physician, physician advisor, and case managers to formulate secondary appeals and written formal appeals using appropriate medical management tools.
• Serve as the expert internal consultant for multiple departments related to regulatory and billing requirements.
• Reviews all surgery cases across the facility pre and post procedure to ensure CPT, LOC, relevant testing, authorization and medical necessity are present in the EMR prior to billing.

Skills

Interpersonal communication

Negotiation

Analytical thinking

Research evidence-based practices

Education

Bachelor's degree

ACMA ACM Certification

CCMC Case Manager

AACN Acute/Critical Care Nursing (Adult, Pediatric & Neonatal)

Registered Nurse

ABMCM Certified Managed Care Nurse

AAMCN Utilization Review Professionals

MCG

ANCC Nursing Case Management

ACMA Case Management Administrator Certification

Job description

Baptist Health is the region's largest not-for-profit healthcare organization, with 12 hospitals, over 29,000 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 26 years, we've been named one of Fortune's 100 Best Companies to Work For, and in the 2025-2026 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 63 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.

Benefits

• 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.

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 $89523.20 - $119065.86 / year depending on experience.

Qualifications

Degrees:

• Bachelors.

Licenses & Certifications:

• ACMA ACM Certification.
• CCMC Case Manager.
• AACN Acute/Critical Care Nursing (Adult, Pediatric & Neonatal).
• Registered Nurse.
• ABMCM Certified Managed Care Nurse.
• AAMCN Utilization Review Professionals.
• MCG.
• ANCC Nursing Case Management.
• ACMA Case Management Administrator 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 3 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: 4 Years

EOE, including disability/vets