[Hiring] Denials & Appeals Administrator @BMC Software

Role Description

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.
• Determines appropriate level of patient care, appropriateness of tests/procedures, and an estimation of the patient’s expected length of stay.
• Secures authorization for the patient’s clinical services through timely collaboration and communication with payers as required.
• 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.

• Obtains information on all denials occurring as related to observation and inpatient stays.
• Researches and responds to denials in a timely fashion.
• Communicates with multiple members of the clinical team in clear concise language, taking the lead in the resolution of the clinical denials.
• 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.
• 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 ensuring a denial appeals process that includes monitoring for patterns and trends and maximizing reimbursement within regulatory requirements.

Qualifications

• Requires Bachelor's Degree in Nursing or related field. Graduate degree preferred.
• Licensed to practice professional nursing as a registered nurse in the Commonwealth of Massachusetts.

Requirements

• Minimum 5 years or more related experience, preferably in a healthcare case management and patient insurance/billing environment.
• 3-4 years supervisory experience preferred.
• Medical records coding experience is desirable.

Knowledge and Skills

• Comprehensive knowledge of clinical documentation and medical coding.
• Working knowledge of patient financial billing regulations/requirements, reimbursement, and managed care.
• Ability to review, interpret, and analyze clinical and patient financial reports and data.
• Understanding of medical records coding, patient billing policies and procedures, and health insurance standards.
• Knowledge of supervisory/managerial techniques and principles.
• Advanced interpersonal skills necessary to work with physicians, hospital directors, and managers.

Compensation Range

$43.03 - $62.50. 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.

Benefits

• Medical, dental, vision, and pharmacy benefits.
• Discretionary annual bonuses and merit increases.
• Flexible Spending Accounts.
• 403(b) savings matches.
• Paid time off.
• Career advancement opportunities.
• Resources to support employee and family well-being.

Equal Opportunity

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