Denials and Appeals RN Administrator - Remote

Overview

The RN Appeal Administrator is responsible for managing the psychiatric pre-denial and appeal processes, ensuring that patient placements are appropriate according to accepted criteria, and securing necessary authorizations through effective communication with payers.

In Short

• Manage psychiatric pre-denial and appeal processes.
• Conduct Utilization Reviews for patient placements.
• Use medical necessity screening tools for reviews.
• Collaborate with payers for service authorization.
• Ensure compliance with CMS Conditions of Participation.
• Maintain comprehensive knowledge of clinical documentation.
• Supervise and train staff in billing and compliance.
• Analyze clinical and financial reports.
• Implement financial policies and plans.
• Promote health equity and exceptional care.

Requirements

• Nursing degree (Diploma, ASN or BSN preferred).
• MA RN License required.
• CCM or ACM certification preferred.
• 3-5 years of related experience in healthcare case management.
• 3-4 years of supervisory experience preferred.
• Knowledge of clinical documentation and medical coding.
• Understanding of patient financial billing regulations.
• Excellent interpersonal skills.
• Ability to analyze and interpret complex data.
• Experience in clinical areas and patient financial management.

Benefits

• Opportunity to make a difference in community health.
• Supportive team environment.
• Recognition as a top employer.
• Commitment to employee health and safety.
• Equal employment opportunities.
• Access to training and development resources.
• Comprehensive benefits package.
• Focus on health equity initiatives.
• Flexible work arrangements.
• Participation in the Electronic Employment Verification Program.