Denials Management Appeals Coordinator – RN
- Responsible for any claim denials regarding medical necessity and authorization and acts as a resource to outside departments relative to the denials process.
- Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is required.
- Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable.
- Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments, where an appeal is warranted.
- Responsible for governmental payer audits, Medicaid MCO Audits, and Medicare Advantage audits (i.e RAC and Cost Outlier).
- Provides patterns or trends associated with denials and appeals to Denials Management leadership.
- Maintains understanding of payer contracts.
- Maintains clinical competency and current knowledge of regulatory and payor requirements to perform job responsibilities.
- Collaborates with other departments, such as Case Management and MPA practices, in regards to appeals and denials.
- Working knowledge of managed care terminology, managed care reimbursement methodologies, and billing/coding terminology (i.e. ICD-10, CPT, Revenue Code) preferred.
- Procedural knowledge of Patient Financial Services.
- Understanding of basic revenue cycle.
- Excellent interpersonal, written and organizational skills required.
- Attention to detail and accuracy skills required.
- Microsoft Excel and Word knowledge required.
- Minimum of 2 years healthcare appeals experience preferred
- Must possess a valid RN license
Florence, SC, United States