Job Details

Denial & Appeals Coordinator, Concurrent Denials Prevention, FT, 8A-4:30P

Job: Nursing
Facility: Corporate,
Primary Location: Miami
Job Schedule: Full-time
Job ID: 89162

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About Baptist Health South Florida:

Baptist Health South Florida is once again one of the 2019 Fortune 100 Best Companies to Work For! This is the 19th time Baptist Health has been recognized on the list. We have also been recognized for being among the best healthcare providers in the nation by U.S. News & World Reports in its 2018-2019 Best Hospitals report.


Baptist Health South Florida is the region’s largest not-for-profit healthcare organization with more than 23,000 employees working across 11 hospital campuses and more than 100 outpatient facilities throughout Miami-Dade, Monroe, Broward, and Palm Beach counties. In 2016 we welcomed the newest weapon in the fight against cancer, the world-class Miami Cancer Institute and proton therapy center. Everything we do at Baptist Health, we do to the best of our ability. That includes supporting our team with extensive training programs, millions of dollars in tuition assistance, comprehensive benefits and more. Working within our award-winning culture means getting the respect and support you need to do your best work ever. Find out why this is the best place to be your best!

Job 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



Licenses & Certifications: 
CCMC Case Manager 
AACN Acute/Critical Care Nursing (Adult, Pediatric & Neonatal) 
ABMCM Certified Managed Care Nurse 
AAMCN Utilization Review Professionals 
ANCC Nursing Case Management Registered Nurse 
ACM Certification 
CCM 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 5 years of hire.
RN license & one of the listed certifications is required.
Three 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 standards. 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: 

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