Coordinator-Denial and Appeals
Northeast Georgia Health System - Gainesville, GA

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Bachelor's
  • RN - Registered Nurse
  • 3 Years of Experience Required
  • Supports denials, appeals and compliance activities within the Payer Audit and Clinical Denials Management Department. Conducts audits to ensure activities conform with regulatory requirements. Supports policy development, implementation, and staff /physician education relative to management of payer denials from all payers, Federal and State payers, as well as, commercial managed care payers. As an active participant of the Revenue Cycle Committee, this position supports managed care activities, appeal documentation and defense processes representing the Organization both internally and externally. The position works both independently and with the multidisciplinary team to evaluate and improve denial management activity, documentation, and the appeal process. The primary goal is to assess clinical care rendered to the patient that is billed to the payer and to recover all appropriate funding where indicated. This position is instrumental in determining root causes based on denial activity and recommending standard work for clinical staff and providers. The overriding goal is to minimize any loss in revenue and maintain and/or improve the Organization's compliance with documentation, coding and billing activities.

    Licensed Registered Nurse in State of Georgia

    Must be able to demonstrate knowledge and skills necessary to provide care appropriate to patients served. Excellent interpersonal communication and negotiation skills. Strong analytical, data management and PC skills. Current working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement. Knowledge of third party regulations is fundamental to the position and required. 3-5 years Case or Utilization Management experience, which would include acute med-surg and/or critical care experience required. Must have expertise with InterQual and Milliman disease management ideologies. In-depth familiarity with third party billing requirements and regulations, and billing documentation requirement preferred.

  • Northeast Georgia Health System - 15 months ago - save job - copy to clipboard
    About this company
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    Northeast Georgia Health System in Gainesville, Georgia, is a not-for-profit community health system, dedicated to improving the health and...