Senior Denials & Appeals Specialist

Baptist Health; Town of Florida (NY); On-site; USD 90,000 - 119,000; Full time

Benefits offered by this job

Career growth

Health and wellness

Deductible wellness program

Tuition reimbursement

Job summary

Baptist Health, a leading not-for-profit health system, is seeking a senior Case Management expert to ensure medical necessity and efficient resource use across services. You will review denials, coordinate appeals, and collaborate with physicians and payor partners to support compliant reimbursement.

The role requires RN licensure, a BSN or related degree, and 4+ years in hospital case management or utilization review, with strong analytical and communication skills.

Qualifications

• Bachelor's degree required.
• RN license and listed certifications required.
• Minimum 4 years of hospital Case Management or Utilization Review experience.

Responsibilities

• Serve as senior expert consultant for Case Management to ensure medical necessity and appropriate resource use.
• Evaluate denials and assist with appeals for payors (MCG/Interqual/CMS).
• Collaborate with attending physicians, physician advisors and case managers to formulate appeals.
• Act as liaison across departments (HSS, PFS, Compliance, Surgery, Transfer Center) on regulatory and billing requirements.
• Review surgery cases to ensure CPT/LOC/testing/authorization before billing.

Job description

Baptist Health, a leading not-for-profit health system, is seeking a senior Case Management expert to ensure medical necessity and efficient resource use across services. You will review denials, coordinate appeals, and collaborate with physicians and payor partners to support compliant reimbursement.

The role requires RN licensure, a BSN or related degree, and 4+ years in hospital case management or utilization review, with strong analytical and communication skills.