Appeals Coordinator

Job Summary:
The Appeals Coordinator is responsible for the review, response (including appeals), and trending of inpatient denials received at Erlanger Health System, including elective surgery, infusions, imaging, and others. This includes reviewing or ascertaining reason for denial, gathering pertinent data needed for response to denial and adhering to all timeframes established by the reviewing entity. This Position reports to the RI director. The Appeals Coordinator is responsible for identifying trends related to audits results and communicating through the established reporting mechanism. The Appeals Coordinator is responsible for communicating with physicians and other administrative staff as needed to obtain documentation needed for timely response to audit requests and/or appeals. Ability to understand and work within EPIC WQ's.

Education:
Required:
Bachelor's Degree in Nursing or other Clinically Appropriate Healthcare Profession (RRT, RHIT). An Associate's Degree will be considered if the applicant has extensive utilization, coding and compliance audit experience.

Preferred:
Registered Nurse (RN)

Experience:
Required:
Broad Clinical Experience required. Minimum of 5 years prior utilization review/ case management experience in the acute care setting. Demonstrated ability to coordinate and respond to competing priorities. Demonstrated ability to work effectively with professionals in diverse disciplines. Must be computer literate and demonstrate ability to prioritize tasks and timeframes.

Preferred:
N/A

Position Requirement(s): License/Certification/Registration
Required:
TN RN License or other Clinical Licensure in State of Tennessee

The Nurse Licensure Compact will not change how to obtain or renew a Tennessee license. However, the Tennessee nursing license will be a single state license for Tennessee Residents or non-compact state residents. Tennessee licensure or multistate licensure from a compact state must be obtained within three months of hire for non-Tennessee residents.

Preferred:
TN RN License and Certified in Healthcare Compliance (CHC), Certified Professional Coder (CPC-H), or Certified Coding Specialist (CCS).

Department Position Summary:
The Appeals Coordinator reviews, responds to, and tracks the trends of Audit requests and inpatient or outpatient denials received at the Erlanger Health System. The Appeals Coordinator needs to integrate any regulatory changes, coding changes, payment system changes, or other changes that might have an effect on the core responsibilities. The Appeals Coordinator reports to the RI director and will assist with other assigned projects as needed.

Audits include requests from the Medicare administrative Contractor (MAC); which includes Additional Development Requests (ADR), CERT, QIO, third party contracted entities and other targeted areas. Additionally, Audit requests may also come from Recovery Audit Contractor requests (RAC), Medicaid Integrity Program Requests (MIP)), and other yet to be determined federally mandated audits - all of these Audit requests fall under the responsibility of the Appeals Coordinator.

As a part of tracking the trends of Audit requests and denials, the Appeals Coordinator reviews, responds, and tracks all outlier requests - be it from federal, state, or managed care payers, and initiates the appeals process as needed. Similarly, the Appeals Coordinator must identify trends related to audits results, and communicate the findings through the established reporting mechanism.

The Appeals Coordinator must be able to communicate with physicians and other administrative staff as needed, to obtain documentation needed for timely responses to audit requests and/or appeals. Communication with Utilization Review is also key.

The Appeals coordinator must be proficient in evidence based clinical screening criteria, MCG and InterQual and be able to apply the criteria to expertly written appeal letters. Furthermore, the Appeals Coordinator must be able to understand and work within EPIC work queues, and have excellent time management skills. Finally, given the scope of responsibility, the Appeals Coordinator must have a strong understanding of the Revenue Cycle, proper coding principles, and a solid grasp of the payment and charge capture systems.