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: Registered Nurse Department: Denial/Appeal Administrator Schedule: W eekend, (Saturday, Sunday, Monday), Evening, 8 hour shifts , 4p-12:30a Education JOB REQUIREMENTS Nursing degree: Diploma, ASN or BSN (preferred), Ability to obtain BSN within 4 years Certificates, Licenses, Registrations Required Licensed to practice as a Registered Nurse in the Commonwealth of Massachusetts Experience Minimum 5 years or more related experience in a Utilization Management, Denials and Appeals and patient insurance/billing 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. Eligible for weekend differentials Equal Opportunity Employer/Disabled/Veterans...Style is never in short supply at our more than 500 HomeGoods stores and we are constantly on a mission to provide the little surprises and extra touches that make a house feel like home. Same with working here. Our environment is ever-changing, yet always encouraging....
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