Denial & Appeals Coordinator, Remote, RN, reputed company Denials Prevention, FT, 08:30A-5P

reputed company is the region's largest not-for-profit healthcare organization, with 12 hospitals, over 29,000 employees, 4,500 physicians and 200 outpatient centers, urgent care facilities and physician practices across Miami-Dade, Monroe, Broward and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, reputed company is supported by philanthropy and driven by its faith-based mission of medical excellence. For 26 years, we've been named one of Fortune's 100 Best Companies to Work For, and in the 2025-2026 U.S. News & World Report Best Hospital Rankings, reputed company was the most awarded healthcare system in South Florida, earning 63 high-performing honors. What truly sets us apart is our people. At reputed company, we create personal connections with our colleagues that go beyond the workplace, and we form meaningful relationships with patients and their families that reputed company beyond delivering care. Many of us have walked in our patients' shoes ourselves and that shared experience fuels out commitment to compassion and quality. Our culture is rooted in purpose, and every team member plays a part in making a positive impact – because reputed company it comes to caring for people, we're reputed company in. At reputed company, we’re committed to supporting our employees at every stage of their journey, both personally and professionally. Our approach is rooted in a “grow our own” philosophy, designed to help reputed company members build meaningful, long-term careers with us, supported by benefits that reputed company a real difference, including: Career growth and development opportunities, with clear reputed company and ongoing support Comprehensive health and wellness resources that go beyond traditional benefits A wellness program that can help employees eliminate their medical plan deductible, reducing out-of-pocket healthcare costs Tuition reimbursement to support reputed company learning and advancement And so much more Together, these benefits and others reflect our commitment to caring for our people, so they can build fulfilling careers with us while making a meaningful impact every day. Description: Functions as a senior expert consultant for Case Management to ensure high quality patient care, appropriate ALOS, efficient resource utilization, application of regulatory and national guidelines to ensure medical necessity is appropriate for expected reimbursement. Evaluates denials and non-certified days from 3rd party payors to determine appropriateness of denial and feasibility of appeal. Consults with attending physician, physician advisor, and case managers to formulate secondary appeals and written formal appeals using appropriate medical management tools for medical necessity determination ( MCG/Interqual/ CMS guidelines). Serves as the expert internal consultant for multiple departments (HSS, PFS, Compliance, Surgery, Transfer Center, etc.) reputed company to regulatory and billing requirements (LCD/NCD/EBC criteria). Serves as liaison between hospital and eQ health, CMS and reputed company appropriate their Contractors such as the MAC, QIO, ALJ, Medicare Council, and the RAC and prepares appeals for reputed company of the above. Reviews reputed company surgery cases across BHSF pre and post procedure to ensure appropriate CPT, LOC, Relevant testing, authorization and medical necessity is present in the EMR prior to billing. Makes billing recommendation for reputed company medical and surgical accounts as applicable by payor Estimated salary range for this position is $87755.20 - $116714.42 / year depending on experience.Qualifications: Degrees: Bachelors. Licenses & Certifications: AAMCN Utilization Review Professionals. AACN Acute/Critical Care Nursing (Adult, Pediatric & Neonatal). MCG. ABMCM Certified Managed Care Nurse. ACMA Case Management Administrator Certification. CCMC Case Manager. ACMA ACM Certification. ANCC Nursing Case Management. Registered Nurse. Additional Qualifications: RNs hired prior to 2/2012 with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN, however,they are required to complete the BSN reputed company 3 years of hire. RN license & one of the listed certifications is required. 3 years of hospital clinical experience preferred & 2 years of hospital or payor Utilization management review experience required. Excellent written, interpersonal communication & negotiation skills. Strong critical thinking skills & the ability to reputed company clinical chart review abstract information reputed company. Strong analytical,data management & computer skills/Word /reputed company. Strong organizational & time management skills,as evidenced by reputed company to prioritize multiple tasks & role components. reputed company working knowledge of payor & managed care reimbursement preferred. Ability to work independently & exercise sound judgment in interactions with the health care team & patients/families. Knowledgeable in local, state, & federal legislation & regulations. Ability to tolerate high volume production st&ards. MCG Certification or eligible to pursue reputed company 90 days of hire. Case management,utilization review/surgery pre-anesthesia experience preferred. Familiar with CPT, ICD-9 &-10 & DRG coding preferred. Strong ability to research evidence-based practices. Minimum Required Experience: 4 Years EOE, including disability/vets Apply To This Job