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Baptist Health South Florida Coral Gables, United StatesFunctions 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 de ...
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Baptist Hospital of Miami Miami, United States Full timeBaptist Health South Florida is the region's largest not-for-profit healthcare organization with 12 hospitals, more than 27,000 employees, 4,000 physicians, and 200 outpatient centers, urgent care facilities, and physician practices spanning across Miami-Dade, Monroe, Broward, an ...
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Baptist Health South Florida Miami, United States Full time· Baptist Health South Florida is the region's largest not-for-profit healthcare organization with 12 hospitals, more than 27,000 employees, 4,000 physicians, and 200 outpatient centers, urgent care facilities, and physician practices spanning across Miami-Dade, Monroe, Broward, ...
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Baptist Health South Florida Miami, United States Full time· Baptist Health South Florida is the largest healthcare organization in the region, with 12 hospitals, more than 24,000 employees, 4,000 physicians and 100 outpatient centers, urgent care facilities and physician practices spanning across Miami-Dade, Monroe, Broward and Palm Be ...
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Baptist Health South Florida South Miami, United States Full time· Baptist Health South Florida is the largest healthcare organization in the region, with 12 hospitals, more than 24,000 employees, 4,000 physicians and 100 outpatient centers, urgent care facilities and physician practices spanning across Miami-Dade, Monroe, Broward and Palm Be ...
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Baptist Health Coral Gables, United States Full timeBaptist Health South Florida is the largest healthcare organization in the region, with 12 hospitals, more than 24,000 employees, 4,000 physicians and 100 outpatient centers, urgent care facilities and physician practices spanning across Miami-Dade, Monroe, Broward and Palm Beach ...
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Baptist Health South Florida Miami, United States Full time· Baptist Health South Florida is the region's largest not-for-profit healthcare organization with 12 hospitals, more than 27,000 employees, 4,000 physicians, and 200 outpatient centers, urgent care facilities, and physician practices spanning across Miami-Dade, Monroe, Broward, ...
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Baptist Health South Florida Miami, United States Full time· Baptist Health South Florida is the largest healthcare organization in the region, with 12 hospitals, more than 24,000 employees, 4,000 physicians and 100 outpatient centers, urgent care facilities and physician practices spanning across Miami-Dade, Monroe, Broward and Palm Be ...
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Baptist Health South Florida Miami, United States Full time· Baptist Health South Florida is the largest healthcare organization in the region, with 12 hospitals, more than 27,000 employees, 4,000 physicians and 100 outpatient centers, urgent care facilities and physician practices spanning across Miami-Dade, Monroe, Broward and Palm Be ...
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Baptist Health South Florida Miami, United States Full time· Baptist Health South Florida is the region's largest not-for-profit healthcare organization with 12 hospitals, more than 27,000 employees, 4,000 physicians, and 200 outpatient centers, urgent care facilities, and physician practices spanning across Miami-Dade, Monroe, Broward, ...
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Baptist Health South Florida Coral Gables, United States Full time· Baptist Health South Florida is the region's largest not-for-profit healthcare organization with 12 hospitals, more than 27,000 employees, 4,000 physicians, and 200 outpatient centers, urgent care facilities, and physician practices spanning across Miami-Dade, Monroe, Broward, ...
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Baptist Health South Florida Miami, FL, United StatesThe purpose of the RN Case Manager I position is to support the physician and interdisciplinary team in facilitating patient care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care. The role integr ...
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Baptist Health South Florida Miami, United States Full time· Baptist Health South Florida is the largest healthcare organization in the region, with 12 hospitals, more than 24,000 employees, 4,000 physicians and 100 outpatient centers, urgent care facilities and physician practices spanning across Miami-Dade, Monroe, Broward and Palm Be ...
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Baptist Health South Florida Miami, United States Full time· Baptist Health South Florida is the region's largest not-for-profit healthcare organization with 12 hospitals, more than 27,000 employees, 4,000 physicians, and 200 outpatient centers, urgent care facilities, and physician practices spanning across Miami-Dade, Monroe, Broward, ...
Denial & Appeals Coordinator, RN, Concurrent Denials Prevention, FT, 08:30A-5P - Coral Gables, United States - Baptist Health South Florida
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 payorEstimated salary range for this position is $ $ / year depending on experience.
Degrees:
Bachelors
Licenses & Certifications:
AAMCN Utilization Review Professionals
AACN Acute/Critical Care Nursing (Adult, Pediatric & Neonatal)
MCG
ABMCM Certified Managed Care Nurse
CCMC Case Manager
ACMA ACM Certification
Registered Nurse
ANCC Nursing Case Management
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.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:
3
