Clinical Rn Appeals Coordinator

Company: Cooper University Health Care
Location: Camden
Posted on: January 25, 2023

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