Coordinator, Appeal & Denials - Care Coordination - Vineland

MAJOR FUNCTION:

The Denial and Appeals Coordinator tracks and coordinates third party payer activity and timeliness of organizational response. Identifies, analyzes, and reports denial trends to the department Director, Business Office, Compliance and Managed Care. Maintains monthly reports on internal UM trends including referral volumes and referral outcomes. Participate in Compliance Committee and Denials Committee meetings as appropriate. Serves as a resource to case managers relative to retrospective and concurrent denials and UM processes.  Develop educational materials for UM team in conjunction with the Care Coordination Director. Serves as a liaison between case managers, payers, and internal physician advisors in response to payer issues. Collaborates with internal and external stakeholders to ensure compliance to state and national rules and regulations along with payer contracts. Participates in development, review and revision of Care Coordination policies and procedures related to the UM process. Coordinates, tracks and assists with appeals involving the Quality Improvement Organization (QIO). Performs root cause analyses to educate and inform internal process improvement. Maintains clinical competency and current knowledge of regulatory and payor requirements to perform job responsibilities. Point of contact for internal and external teams regarding screening tools (i.e. MCG, Interqual).  This position is responsible for providing data-driven insights and reports to leadership, monitoring key metrics related to Utilization Management, and supporting the professional development of the team through mentorship and training. 

QUALIFICATIONS:

Education & Experiences:

• BSN required; MSN preferred.
• Registered Nurse licensure required.
• Minimum of three years clinical nurse experience.
• Minimum of 3 years of utilization review experience required.
• Minimum of 2 years recent case management experience required. 
• Ongoing experience with payer portals and provider manuals as well as CMS regulations.     

Certification/Licensure: 

• Registered Nurse License Required

Knowledge & Skills:

• Demonstrates role-modeling behavior through professional and effective interpersonal communication with staff and external stakeholders.
• Ability to work independently and set priorities efficiently under constraints of managed care guidelines.
• Ability to coordinate, compile, and analyze data. Maintain denial tracker and UM report (LOS, denial rate, turn around times, UM outliers)
• Excellent communication skills (oral and written) and interpersonal skills necessary to negotiate with families, patients, post-acute providers and third- party payors. 
• Understanding of payer portals and provider manuals 

BENEFITS INFORMATION:

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At Inspira Health, you’ll join with the area’s most dedicated and distinguished team to bring quality and compassionate care to our communities. We focus on clinical excellence, providing evidence-based care to help each patient achieve the best possible outcome. The scope and depth of our network can open many doors for your learning and career growth.

Our charitable nonprofit health care organization serves communities across southern New Jersey. The network, which traces its roots to 1899, comprises three hospitals, a comprehensive cancer center, sleep medicine, cardiac testing, digestive health and wound care, urgent care, imaging and rehabilitation, and primary and specialty physician practices in Gloucester, Cumberland, Salem and Camden counties.

Inspira is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, religion, creed, color, national origin, ancestry, age, marital status, affectional or sexual orientation, familial status, disability, liability for service in the Armed Forces of the United States, nationality, sex, gender identity or expression.