About the position
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.) related to regulatory and billing requirements (LCD/NCD/EBC criteria). Serves as liaison between hospital and eQ health, CMS and when appropriate their Contractors such as the MAC, QIO, ALJ, Medicare Council, and the RAC and prepares appeals for all of the above. Reviews all 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 all medical and surgical accounts as applicable by payor.
Responsibilities
- Evaluate denials and non-certified days from 3rd party payors to determine appropriateness of denial and feasibility of appeal.
- Consult 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).
- Serve as the expert internal consultant for multiple departments (HSS, PFS, Compliance, Surgery, Transfer Center, etc.) related to regulatory and billing requirements (LCD/NCD/EBC criteria).
- Serve as liaison between hospital and eQ health, CMS and when appropriate their Contractors such as the MAC, QIO, ALJ, Medicare Council, and the RAC and prepares appeals for all of the above.
- Review all 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.
- Make billing recommendations for all medical and surgical accounts as applicable by payor.
Requirements
- RN license & one of the listed certifications is required.
- 2 years of hospital or payor Utilization management review experience required.
- Excellent written, interpersonal communication & negotiation skills.
- Strong critical thinking skills & the ability to perform clinical chart review abstract information efficiently.
- Strong analytical,data management & computer skills/Word /Excel.
- Strong organizational & time management skills,as evidenced by capacity to prioritize multiple tasks & role components.
- 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 within 90 days of hire.
- Minimum Required Experience: 4 Years
Nice-to-haves
- 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.
- 3 years of hospital clinical experience preferred.
- Current working knowledge of payor & managed care reimbursement preferred.
- 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.
Benefits
- Career growth and development opportunities, with clear pathways 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 continued learning and advancement
About the Denial & Appeals Coordinator, Remote, RN, Concurrent Denials Prevention, FT, 08:30A-5P Opportunity
Baptist Health South Florida is currently hiring for a Denial & Appeals Coordinator, Remote, RN, Concurrent Denials Prevention, FT, 08:30A-5P position based in Remote, FL, US. This is a full time opportunity suited to candidates who are ready to contribute their skills and grow within a dynamic team environment. Whether you're an experienced professional or looking to take the next step in your career, this role offers a chance to work on meaningful projects while developing new capabilities.
What the Role Involves
As a Denial & Appeals Coordinator, Remote, RN, Concurrent Denials Prevention, FT, 08:30A-5P, you will be expected to collaborate closely with cross-functional teams, take ownership of key deliverables, and contribute ideas that help Baptist Health South Florida achieve its goals. Day-to-day responsibilities typically include planning and prioritizing tasks, communicating progress with stakeholders, maintaining high standards of quality, and adapting to evolving business needs. The exact scope of duties may vary depending on team structure and current priorities, so candidates should be comfortable with a role that can evolve over time.
Who Baptist Health South Florida is Looking For
Successful candidates generally bring a combination of relevant experience, strong communication skills, and a proactive attitude toward problem-solving. Baptist Health South Florida values individuals who can work independently as well as part of a team, who are detail-oriented, and who bring a positive, adaptable mindset to their work. Prior experience in a similar Denial & Appeals Coordinator, Remote, RN, Concurrent Denials Prevention, FT, 08:30A-5P capacity is beneficial, though a strong willingness to learn and grow is equally important.
Compensation and Benefits
This role offers a compensation package of approximately USD 87755 - 116714 per year, commensurate with experience. In addition to base pay, many roles at Baptist Health South Florida may include benefits such as health coverage, paid time off, opportunities for professional development, and a supportive work culture designed to help employees thrive both personally and professionally.
Why Join Baptist Health South Florida?
Joining Baptist Health South Florida as a Denial & Appeals Coordinator, Remote, RN, Concurrent Denials Prevention, FT, 08:30A-5P means becoming part of a team that values collaboration, innovation, and continuous improvement. Employees are encouraged to bring their own perspective to the table, and the organization aims to foster an environment where people feel supported in doing their best work. This is a great opportunity for candidates who want their contributions to have a real, visible impact.
How to Apply
If you believe you're a strong fit for the Denial & Appeals Coordinator, Remote, RN, Concurrent Denials Prevention, FT, 08:30A-5P role at Baptist Health South Florida in Remote, FL, US, we encourage you to review the full job details above and submit your application through the listed channel. This position was posted on 2026-06-17T00:00:00Z. Early applications are generally encouraged, as competitive roles like this one can attract a high volume of interest.
