Offer summary

Qualifications:

Nursing degree (Diploma, ASN, or BSN preferred) with the ability to obtain a BSN within 4 years., Licensed to practice as a registered nurse in Massachusetts., Minimum of 5 years of experience in healthcare case management and patient insurance/billing environment., Comprehensive knowledge of clinical documentation, medical coding, and patient financial billing regulations..

Key responsabilities:

Manage the pre-denial, denial, and appeal processes for patient care.

Conduct medical necessity screenings using tools like InterQual or MCG criteria.

Secure authorization for clinical services through collaboration with payers.

Review and analyze clinical and financial reports to ensure appropriate patient care levels.

Job description

POSITION SUMMARY:

The RN Appeal Administrator will be responsible for Pre-denial/ Denial and appeal process in addition to Medical/Surgical and Psychiatric 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 treatment 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: Denial and Appeal RN Administrator

Department: Denials Access

Schedule: 40 Hours (Days)

JOB REQUIREMENTS

EDUCATION:

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

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 environment highly 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 Utilization 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

Required profile