BaltimoreRecruiter Since 2001
the smart solution for Baltimore jobs

Appeals Coordinator

Company: Medstar Research Institute
Location: Baltimore
Posted on: June 12, 2021

Job Description:

Job Summary Reviews and evaluates external denials for medical necessity. Coordinates and monitors the preventivedenial and appeals process. Minimum Qualifications Education/Training Valid RN license in the State of Maryland; Bachelor#s degree in Nursing preferred. # Experience 5 years clinical experience; 5 years experience in utilization management and appealsdecision and writing; case management, quality management, or discharge planning experience preferred. # License/Certification/Registration Certification in Utilization Review, Case Management, and Health Care Qualitypreferred. # Knowledge, Skills # Abilities Excellent verbal and written communication skills. Working knowledge of word processing softwareapplications preferred. Primary Duties and Responsibilities Completes appeal process for denied days for medical necessity that meets Interqual criteria, or appear to be clinically justified. Completes evaluation of all external denials for medical necessity received by the hospital, i.e., first, second, and third level, including potential cases for referral to the State Insurance Commissioner. Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations. Coordinates decision making regarding the feasibility of initiating an appeal for each external denial for medical necessity. Develops medical summaries of denied cases for review by hospital administration and for possible legal/Maryland Insurance Administrative (MIA) action, where indicated. Identifies strategies to avoid denials and improve efficiency in delivery of care through review and examination of denials. Identifies system delays in service to improve the provision of efficient and timely patient care. Identifies process issues related to the concurrent Case Management system, including appropriate resource utilization and identification of avoidable days. Maintains records of concurrent and retrospective denial activity in conjunction with Case Management support staff. Monitors and tracks denials and appeal results, and coordinates information with Patient Financial Services (PFS). Reports data to the Director and Operations Review Committee. Meets with attending physicians and Physician Advisor, as appropriate, to clarify or collect information in the process of development of appeal letters. Participates in meetings and on committees and represents the department and hospital in community outreach efforts as required. Participates in the educational process for physicians and hospital staff to address issues that impact the number and type of denials. Serves as a resource to all staff in areas of utilization review/management. Performs other duties as assigned. Utilizes and analyzes current medical/clinical information as well as medical record information to complete appeal letters.

  • Job Summary
  • Reviews and evaluates external denials for medical necessity. Coordinates and monitors the preventivedenial and appeals process.

  • Minimum Qualifications
  • Education/Training
  • Valid RN license in the State of Maryland; Bachelor's degree in Nursing preferred.

  • Experience
  • 5 years clinical experience; 5 years experience in utilization management and appealsdecision and writing; case management, quality management, or discharge planning experience preferred.

  • License/Certification/Registration
  • Certification in Utilization Review, Case Management, and Health Care Qualitypreferred.

  • Knowledge, Skills & Abilities
  • Excellent verbal and written communication skills. Working knowledge of word processing softwareapplications preferred.

  • Primary Duties and Responsibilities
  • Completes appeal process for denied days for medical necessity that meets Interqual criteria, or appear to be clinically justified.

  • Completes evaluation of all external denials for medical necessity received by the hospital, i.e., first, second, and third level, including potential cases for referral to the State Insurance Commissioner.

  • Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations.

  • Coordinates decision making regarding the feasibility of initiating an appeal for each external denial for medical necessity.

  • Develops medical summaries of denied cases for review by hospital administration and for possible legal/Maryland Insurance Administrative (MIA) action, where indicated.

  • Identifies strategies to avoid denials and improve efficiency in delivery of care through review and examination of denials.

  • Identifies system delays in service to improve the provision of efficient and timely patient care. Identifies process issues related to the concurrent Case Management system, including appropriate resource utilization and identification of avoidable days.

  • Maintains records of concurrent and retrospective denial activity in conjunction with Case Management support staff. Monitors and tracks denials and appeal results, and coordinates information with Patient Financial Services (PFS). Reports data to the Director and Operations Review Committee.

  • Meets with attending physicians and Physician Advisor, as appropriate, to clarify or collect information in the process of development of appeal letters.

  • Participates in meetings and on committees and represents the department and hospital in community outreach efforts as required.

  • Participates in the educational process for physicians and hospital staff to address issues that impact the number and type of denials. Serves as a resource to all staff in areas of utilization review/management.

  • Performs other duties as assigned.

  • Utilizes and analyzes current medical/clinical information as well as medical record information to complete appeal letters.

Keywords: Medstar Research Institute, Baltimore , Appeals Coordinator, Other , Baltimore, Maryland

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category
within


Log In or Create An Account

Get the latest Maryland jobs by following @recnetMD on Twitter!

Baltimore RSS job feeds