Senior RN, Denials & Appeals | Case Management Expert

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 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.