[Hiring] Denials & Appeals RN 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 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:

• 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.
• 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.

Requirements

• Comprehensive knowledge of clinical documentation and medical coding.
• Working knowledge of patient financial billing regulations/requirements, reimbursement, 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.

Benefits

• Generous total compensation including benefits (medical, dental, vision, pharmacy).
• 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.

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. 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.

Equal Opportunity

Equal Opportunity Employer/Disabled/Veterans. According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not ask or require downloads of any applications, or “apps” job offers are not extended over text messages or social media platforms. We do not ask individuals to purchase equipment for or prior to employment.