Clinical Rn Appeals Coordinator
Company: Cooper University Health Care
Location: Camden
Posted on: January 25, 2023
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Job Description:
About usAt Cooper University Health Care, our commitment to
providing extraordinary health care begins with our team. Our
extraordinary professionals are continuously discovering clinical
innovations and enhanced access to the most up-to-date facilities,
equipment, technologies and research protocols. We have a
commitment to its employees by providing competitive rates and
compensation, a comprehensive employee benefits programs,
attractive working conditions, and the chance to build and explore
a career opportunity by offering professional development.
-Discover why Cooper University Health Care is the employer of
choice in South Jersey. - Short Description The Denials & Appeals
RN is responsible for the retroactive medical necessity review of
medical services provided. The position is integral in the revenue
cycle and exists to overturn medical necessity clinical denials
through the appeal process. The RN will review and respond to all
assigned payer (Medicare, and Medicaid, and commercial) medical
necessity clinical denials. The RN will identify trends to promote
a reduction in the medical necessity denials. The RN will also
monitor the DOTS portal and Permedion scorecard to ensure all
appeals are submitted and resolved timely. -Coordinates work flow
with utilization review nurses, administrative coordinators and
physician advisors to facilitate all potential recovery of denied
days. -Responsible for data collection and analysis for the
utilization review committee, including source of denials, root
causes of denials and action plan for correction. Coordinates
activities and strategies with the Clinical Utilization Review
Department, Patient Access, Health Information Management, Business
Office, Managed Care, and Physician Advisors. -Conducts
investigations and reviews of medical necessity denials. Reviews
prospective, inpatient, or retrospective medical records of denied
services for medical necessity. -Extrapolates and summarizes
medical information for medical director, consultants, and other
external review. Prepares recommendations using clinical and
regulatory guidelines to either uphold or deny appeal and forwards
to the Physician Advisor for approval. - Discusses with Physician
Advisor as needed to establish the appropriate level of care and/or
plan for appeal. -Generates written appeal correspondence, and
ensures that appeals and grievances are resolved timely within
allotted timeframes. -Utilizes leadership skills and serves as a
subject matter expert for appeals/grievances/quality of care issues
and is a resource for clinical and non clinical team members in
expediting the resolution of outstanding issues. -Maintains
compliance with all federal, state, HIPAA regulations, and
accrediting requirements. - -Experience Required5 years clinical
experience including experience in utilization management, case
management, CDI, insurance, coding, or clinical appeals preferred
-Knowledge and understanding of managed care contract language,
Medicaid, CMS guidelines, and third party payor claim guidelines.
Extensive Knowledge of Interqual and MCG(Milliman) guidelines and
regulatory mandates -Effective problem solving skills and excellent
time management essential. Strong communication skills required,
including the ability to read documents and assimilate ideas to
formulate a strong case for winning an appeal. -Evidence in
leadership, integrity and innovation and the ability to work
independently. Excellent organizational skills and strong computer
skills including EPIC knowledgeEducation RequirementsBSN required,
MSN Preferred; case management, utilization management or other
related certification preferred.Special RequirementsScheduled Days
/ Hours: Monday - Friday, day shift; License (or Certification):CPC
Preferred; License (or Certification):EQUIV Preferred; License (or
Certification):NJ-RN Required; License (or Certification):RHIT
Preferred
Keywords: Cooper University Health Care, Camden , Clinical Rn Appeals Coordinator, Healthcare , Camden, New Jersey
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