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RN Appeals Coordinator

Company: UT Southwestern Medical Center
Location: Dallas
Posted on: January 15, 2021

Job Description:

RN Appeals Coordinator works under general supervision to Manager, Hospital Revenue Cycle. Experience and Education

  • Required - Current Registered Nurse (RN) License
  • Preferred - Associate's or bachelor s degree in Nursing
  • Required - 3 years Hospital based experience in the delivery of patient care as an RN. Experience in Case Management, Utilization Review and/or Discharge Planning in either the Acute Care environment or Managed Care environment. Experience functioning independently and working well within a team setting.
  • Preferred - Experience in Appeal/Denial Management in a hospital setting Job Duties
  • Reviews incoming clinical denials from payers, regulatory and other agencies in respect to clinical medical necessity determinations or prior authorization denials related to medical necessity. Handles written and/or verbal appeals of denials, utilizing clinical documentation to make the case for overturning denials.
  • Identifies, plans, and coordinates aspects of medical necessity reviews with others within UT Southwestern as necessary.
  • Maintains current knowledge of third-party payer and government requirements related to job functions.
  • Maintains minimum standards for licensure and strives for professional/personal development.
  • Adapts behavior to the specific patient population, including but not limited to respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style. Knowledge, Skills & Abilities
  • This job applies clinical expertise as well as knowledge of utilization and discharge planning criteria to review medical information of prior hospitalized patients that are reviewed via the regulatory audit process. Identifies issues and problems such as inappropriate admissions and non-acute hospital days which may adversely impact quality patient care, appropriate utilization of hospital resources, or optimal financial reimbursement to the company. Functions as a liaison with the department and ensures compliance with regulations and alternative level of care options affecting the company's revenue as it relates to all medical necessity audits. Security This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information Any qualifications to be considered as equivalents in lieu of stated minimum require prior approval of Vice President for Human Resources Administration or his/her designee. This position is security-sensitive and thereby subject to the provisions of Texas Education Code 51.215. UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status. Associated topics: cardiothoracic, intensive care, maternal, mhb, neonatal, nurse clinical, recovery, surgery, tcu, unit

Keywords: UT Southwestern Medical Center, Dallas , RN Appeals Coordinator, Healthcare , Dallas, Texas

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