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RN Appeals Coordinator - Relocation Offered!

Location: Clinton
Posted on: May 16, 2022

Job Description:

Job Summary

  • Responsible for the review and evaluation of external denials for medical necessity utilizing the Acute Care Criteria set. Responsible for the coordination and monitoring of the appeals process. Minimum Qualifications
    • Education/Experience
      • Bachelor of Nursing Degree
      • 3-5 years minimum experience in Acute Care Clinical and Acute Care Case Management
      • 3 years minimum experience in Utilization Management is required
      • License/Certification/Registration
        • Maryland Licensed Nurse
        • Current CPR
        • Knowledge, Skills & Abilities
          • Ability to comprehend and follow the policies and procedures for MedStar Southern Maryland Hospital Center.
          • Ability to read, write and speak or communicate in English to successfully accomplish the essential duties of the position.
          • Ability to demonstrate ethical behavior that supports the hospital's mission, values and commitment to compliance with all federal, state and regulatory laws. Inspires trust and exhibits honesty and integrity within the scope of daily activities.
          • Exhibits professionalism, courtesy and excellent customer service, while interacting with patients, guests and co-workers.
          • Ability to work effectively with people from a variety of culturally diverse backgrounds.
          • Ability to maintain patient confidentiality.
          • Knowledge and ability to utilize a desktop/laptop computer and Word Processing software. Primary Duties and Responsibilities
            • Demonstrates ethical behavior that supports the hospital's mission and values and commitment to compliance with all federal, state and regulatory laws; inspires trust and exhibits honesty and integrity within the scope of daily activities.
            • Completes evaluation of all external denials for medical necessity received by the hospital, i.e., first, second, and third level, including potential cases for referral to the State Insurance Commissioner.
            • Completes evaluation of all cases requiring retrospective reviews and processing.
            • Makes decisions regarding the feasibility of initiating an appeal for each external denial for medical necessity.
            • Completes appeal process for denied days for medical necessity that meet Interqual criteria, Milliman and Robertson Health Management Guidelines (HMG's), or appear to be clinically justified.
            • Utilizes and analyzes current medical/clinical information as well as medical record information to complete appeal letters.
            • Meets with attending physicians or Medical Director, as appropriate, to clarify or collect information in the process of development of appeal letters.
            • Participates in the educational process for physicians, case management department and hospital staff to address issues that impact the number and type of external denials.
            • Monitors and tracks appeal results and coordinates information with the Business Office.
            • Develops medical summaries of denied cases for review by hospital administration and/or attorneys for possible legal action, where indicated.
            • Identifies system bottlenecks/delays in service to improve the provision of efficient/timely patient care. Also, identifies process issues related to the concurrent case management system, including appropriate resource utilization and identification of avoidable days.
            • Maintains records of concurrent and retrospective denial activity in conjunction with UM Analysts. Reports data to the Director and utilization Management Committee.
            • Monitors the use and effectiveness of physician advisor referrals, where indicated.
            • Provides utilization related data to the hospital system; prepares special studies and reports when indicated.
            • Readily distinguishes between acute, intermediate and skilled levels of care.
            • Performs clinical review, upon request of Patient Accounts, for appeals, and Medical Administrative Days.
            • Performs integrated patient care quality monitoring when reviewing cases for appeal:
              • Utilizes Medical Staff approved comprehensive monitors that measure/evaluate:
                • Operative and Invasive Procedures
                • Perinatal
                • Infection Control
                • Stability at Discharge
                • Utilization
                • Case Review
                • Knowledgeable of the organization's performance improvement priorities and outcomes.
                • Supports culture of continuous quality improvement.
                • Uses quality improvement tools and strategies in problem-solving activities.
                • Immediately notifies the Performance Improvement Department of urgent/critical quality issues.
                • Exhibits professionalism, courtesy and excellent customer relations skills, while interacting with patients, guests and co-workers.
                • Communicates with others in an effective, professional manner:
                  • Maintains confidentiality in accordance with hospital policy.
                  • Maintains open communication with MSMHC staff, Medical Staff, Case Management, nursing and health care providers as appropriate.
                  • Communicates effectively, courteously and compassionately to all visitors, physicians, and hospital staff.
                  • Utilizes appropriate channels of communication to address intra departmental and interdepartmental concerns and opportunities for improvement.
                  • Serves as a patient advocate in assuring a collaborative approach to patient care management.
                  • Demonstrates a commitment to professionalism and self-improvement:
                    • Attends required departmental staff meeting.
                    • Participates in performance improvement related education programs.
                    • Participates in The Joint Commission related educational programs.
                    • Participates in related educational programs that promote clinical and case management expertise.
                    • Serves as resource person in all aspects of utilization management for all Medical Staff and ancillary departments to assure hospital compliance with The Joint Commission standards and State and Federal regulations.
                    • Other duties as assigned by Director.
                    • Productivity
                      • Performs work which consistently meets job requirements.
                      • Communicates messages clearly and promptly and is accountable for reporting problems or unusual circumstances to the Director or other appropriate administrative staff.
                      • Sets priorities to maximize the overall effectiveness of the function and completes assignments within scheduled hours.
                      • Initiative
                        • Strives to independently solve problems.
                        • Demonstrates initiative in acquiring knowledge to further understand overall department and hospital functions.
                        • Contributes through constructive suggestions and illustrates resourcefulness.
                        • Dependability
                          • Demonstrates dependability in completing job assignments without supervision.
                          • Assumes responsibility for work performance.
                          • Demonstrates consistent good attendance. About MedStar Health MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation and research. Our 30,000 associates and 5,400 affiliated physicians work in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest visiting nurse association in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar is dedicated not only to teaching the next generation of doctors, but also to the continuing education and professional development of our whole team. MedStar Health offers diverse opportunities for career advancement and personal fulfillment.

Keywords: MEDSTAR HEALTH, Washington DC , RN Appeals Coordinator - Relocation Offered!, Healthcare , Clinton, DC

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