Denials & Appeals MGR

Sapp Bros

Full-time

Merchant Wholesalers, Nondurable Goods

About the position

The position involves managing concurrent denials and appeals in a healthcare setting, ensuring compliance with hospital policies while promoting a patient-centered approach. The role requires effective communication with healthcare team members and patients, as well as the ability to evaluate medical necessity and coordinate appeals processes. The individual will also assist in administrative tasks and maintain organized documentation related to denials and appeals.

Responsibilities

• Promotes a safe, cooperative and professional health care environment to ensure optimum patient care.
• Adheres to all hospital policies, procedures, rules and regulations.
• Makes Customer Service a priority, treating customers in a professional manner and effectively communicating about services.
• Demonstrates standards of performance and behaviors consistent with Patient-Centered Excellence.
• Evaluates concurrent denials from payers for medical necessity and initiates appeal processes.
• Performs retrospective reviews as requested, including short stays and weekend admissions.
• Reviews concurrent denials using Interqual criteria to ensure medical necessity and coordinates appeal processes.
• Reviews elective ambulatory surgery cases to determine appropriateness of inpatient setting.
• Prints and sends medical records of short stays as requested by review agencies.
• Follows up on appeal status and outcomes of concurrent denials and documents appropriately.
• Provides assistance in obtaining authorizations from managed care organizations for delayed placements.
• Assists in the preparation of administrative reports as directed.
• Assists in the completion of PRIs as requested, maintaining training and certification.
• Performs retrospective appeals for At-Risk denials as required.
• Documents concurrent denials and appeals per department policy and maintains a tracking database.
• Maintains organized files of regulatory communications, denials, appeals, and medical records.
• Maintains proficiency in hospital and departmental applications.
• Documents follow-up communications per departmental policy and organizes information for accessibility.
• Identifies problems early and effectively resolves them.
• Uses data effectively for planning and decision making.
• Methodically works toward departmental goals.
• Performs other departmental tasks as requested.

Requirements

• Graduate from a recognized Nursing School or College.
• Current New York State RN License.
• PRI certification within one year of hire.
• 3-5 years clinical nursing experience, preferably in an acute care hospital.
• Minimum of 2 years case management experience required.
• Denials and Appeals experience preferred.
• Managed Care experience preferred.

Nice-to-haves

• Bachelor's Degree preferred.