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Hunterdon Health Care System Appeals Coordinator in Flemington, New Jersey

Position Summary:

The Appeals Coordinator works under the direct supervision of the Administrative Director of Revenue Cycle and will serve as the central point person for preparation of appeals for all inpatient clinical denials. This position has accountability for daily management, monitoring, and response to all inpatient clinical denials.

Primary Position Responsibilities:

Reviews medical record of each denied patient stay applying both Milliman & Interqual quality of care screens, as appropriate. Responds to all written, faxed, and e-mail denial letters timely.

Obtains medical record support, either already existing in the chart, or through subsequent physician querying, in order to prepare a written appeal to the payor for days/stays denied.

Reference any specific payor medical coverage policies necessary when completing the appeal letter. If unsuccessful in initial appeal, continue to the next level of appeal unless medical record documentation does not support doing so.

Keeps a log of all denials received, tracks the applicable processing dates, and ensures that deadlines are not missed. Trends denial reasons and suggests changes to processes in order to reduce the occurrence of these denials.

Makes recommendations of enhancements to the physician documentation process to the Documentation Specialist for implementation. Works closely with Director of Utilization Case Management and the Physician Advisor(s).

Reports summary denial activity to the Administration and presents results to the Utilization Management Committee on a periodic basis.

Participates in meetings with Managed Care Payors as appropriate. Is a member of the Denial Management & Revenue Cycle Committees


Minimum Education -

Required: Associate's degree in nursing or equivalent (nursing diploma) or advanced specialized education or technical training as LPN

Preferred: Bachelor's degree in nursing or related area

Minimum Years of Experience -

Required: Two years appeals experience

Preferred: Five years appeals experience with inpatient and outpatient appeals

License, Registry or Certification -

Required: Current New Jersey RN or LPN licensure

Preferred: Current New Jersey RN or LPN licensure with Medical Coding certification

Knowledge, Skills and/or Abilities -

Required: Demonstrates strong analytical skills.

Demonstrates strong written and verbal communication skills (Word/Excel)

Demonstrates ability to interact successfully with persons at all levels of the organization.

Demonstrates ability to work independently in a productive, goal-oriented manner

Preferred: Knowledge of QuadraMed - Affinity software’s coding compliance module and charge master for insurance billing.