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 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.

The Denials and Appeals Administrator assesses, plans, coordinates, and evaluates initial and ongoing denials. He/She obtains information on all denials occurring as related to observation and inpatient stays. The Denials and Appeals Administrator researches and responds to denials in a timely fashion. He/She communicates with multiple members of the clinical team in clear concise language taking the lead in the resolution of the clinical denials. He/ she identifies trends and responds to the trends by recommending changes in practice and or documentation of the clinical providers to promote a reduction in the denials trends.  The Denials and Appeals Administrator collects and trends the data for the return on investment as it relates to denials and reports that data to the Director Care management for review.

The Denials and Appeals Administrator combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided.  Collaborates with physicians, Case Managers, revenue cycle personnel and payers to appeal denials.  Performs activities related to insuring a denial appeals process that includes monitoring for patterns and trends and maximizing reimbursement within regulatory requirements.

Position: Denials & Appeals Administrator (RN)

Department: Denials Access

Schedule: 40 Hours Days

JOB REQUIREMENTS

EDUCATION:

Requires Bachelor's Degree in Nursing or related field. Graduate degree preferred.

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED :

• Licensed to practice professional nursing as a registered nurse in the Commonwealth of Massachusetts.

EXPERIENCE:

• Minimum 5 years or more related experience preferably in a healthcare case management and patient insurance/billing environment3-4 years supervisory experience preferred.

• Medical records coding experience.is desirable.

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.

Compensation Range:

This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensures as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, BMCHS offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), discretionary annual bonuses and merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family well-being. 

NOTE : This range is based on Boston-area data, and is subject to modification based on geographic location.

Equal Opportunity Employer/Disabled/Veterans

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