Appeals Coordinator
JOB DESCRIPTION: Appeals Coordinator Position Summary :
The position is required to complete denials from Managed care as well as Managed Medicaid/Medicare providers. Logs from the providers are faxed over daily outlining whether the patient is approved for admission and continued stay or denied. The appeals coordinator role is responsible to investigate and follow through with denied admissions and denied days and then coordinate with our physicians to reverse these denials. There is a UR/CM component with this position on the MICU as well which includes 1 st level utilization review for all payers and clinical components of discharge planning.
With the implementation of EHR this position is significant for continued work with our UR physicians and Medical staff to assign and document appropriate level of care and continued use of Milliman guidelines to support admissions and continued stays at the Center. There are strict guidelines for turn around time frames to the appeal process which includes 3 levels of appeals. Overturned admission denials, anddenial of days result in additional revenue to the Center. Although there is cross training and coverage for these duties, for the most part it involves specialized experience.
JOB REQUIREMENTS: Experience :
2 years Utilization Review in acute care hospital required. Basic information on DRG's and contract information. Primary care nursing experience in an acute care hospital setting within a period of no less than 5 years.
Education :
Current NJ RN license. BSN or MSN strongly recommended.
Other Required License/Credentials/Skills :
Excellent interpersonal skills. Excellent clinical nursing skills. Working familiarity with personal computer. Experience with database software preferred.
Contact With Others :
Regular internal and/or external contact involving considerable tact, discretion and persuasion in order to obtain information and/or willing action or consent.
Supervision Given :
None
Supervision Received :
Performs duties independently following established procedures and reporting weekly to immediate supervisor.
