RN Appeals Coordinator - Relocation Offered!
Company: MEDSTAR HEALTH
Posted on: May 16, 2022
- 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
- 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
- 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
- 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
- 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
- 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,
- 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
- 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
- Operative and Invasive Procedures
- Infection Control
- Stability at Discharge
- 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
- 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
- Communicates with others in an effective, professional manner:
- Maintains confidentiality in accordance with hospital
- Maintains open communication with MSMHC staff, Medical Staff,
Case Management, nursing and health care providers as
- 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
- Serves as a patient advocate in assuring a collaborative
approach to patient care management.
- Demonstrates a commitment to professionalism and
- Attends required departmental staff meeting.
- Participates in performance improvement related education
- Participates in The Joint Commission related educational
- 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.
- 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.
- Strives to independently solve problems.
- Demonstrates initiative in acquiring knowledge to further
understand overall department and hospital functions.
- Contributes through constructive suggestions and illustrates
- Demonstrates dependability in completing job assignments
- 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
Keywords: MEDSTAR HEALTH, Washington DC , RN Appeals Coordinator - Relocation Offered!, Healthcare , Clinton, DC
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