Job Description

Job Description

Position Summary

The RN Appeal Administrator will be responsible for the Pre-denial/ Denial and appeal process in addition to Utilization Review, to validate the patient’s placement to be at the most appropriate level of care based on nationally accepted admission criteria. The Appeal/ UR Administrator uses medical necessity screening tools, such as InterQual or MCG criteria, to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient’s expected length of stay. The The Appeal/ UR Administrator secures authorization for the patient’s clinical services through timely collaboration and communication with payers as required. The Appeal/ UR Administrator follows the UR process, in addition to the pre-denial and denial/appeal process as defined in the attached job description and in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review.

Position: Denials and Appeals Administrator

Department: Denials / PreCerts

Schedule: Per Diem

Education

JOB REQUIREMENTS

• Nursing degree: Diploma, ASN or BSN (preferred), Ability to obtain BSN within 4 years

Certificates, Licenses, Registrations Required

• MA RN License
• CCM or ACM certification preferred

Experience

Minimum 3-5 years or more related experience preferably in a healthcare case management and patient insurance/billing environment, required. 3-4 years supervisory experience preferred.

Knowledge And Skills

• Work requires a comprehensive knowledge of clinical documentation and medical coding, and a working knowledge of patient financial billing regulations/requirements, reimbursement, managed care in order to understand the clinical and billing systems; review, interpret, and analyze clinical and patient financial reports and data; and plan, coordinate and prepare for corrections to accounts. Such knowledge is generally acquired through completion of a Bachelor's degree and 5 years of experience in Case Management and an HMO setting.
• Work requires a comprehensive understanding of medical records coding, patient billing policies and procedures and health insurance standards, as well as knowledge of supervisory/managerial techniques and principles in order to control hospital financial billing activities. Establish and implement financial policies and plans; assist with the install of new modules; provide training for staff at various levels. Such knowledge is normally acquired during 5 years or more progressively responsible experience in clinical areas and patient financial management environment.
• Work requires advanced interpersonal skills necessary to work with physicians, hospital directors and managers to affect changes in clinical and fiscal operations, policies and procedures; to provide guidance, communicate and interpret complex patient billing and compliance information.

Equal Opportunity Employer/Disabled/Veterans

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