AHMC Healthcare
Denials (Authorization) Coordinator (PD)
AHMC Healthcare, Riverside, California, United States, 92504
Overview:
Performs quality improvement measures and processes in collaboration with the Case Management Department and Utilization Review Committee. Interprets medical information used in the processing of payments and claimsResponsibilities:Investigates denials by third party payers and crafts thorough appeals to justify medical necessity. Develop, establish, and implement uniform processes and procedures for the successful appeal of payer downgrades and denials in a manner that meets all payer requirements for accuracy and timeliness. Also ensures that appeals are managed within required timeframes for maximum reimbursement. Compiles reports. Prepares and assigns record review for Medical Staff Committees. Assists in determining data formatting and types of indicators and studies. Assist in staff education in preventing denials.Qualifications:Graduate from an accredited school of nursing preferred; baccalaureate degree preferred or > 5 years experience in an acute care facility with denials experience. Possesses both good oral and written communication skills. Demonstrated interpersonal relationships in a manner which enhances communication, promotes conflict resolution and facilitates staff development. Requires knowledge or understanding or integration or software and hardware. Demonstrates a willingness to learn new programs and obtain further education regarding computerization. Knowledge in ICD Coding preferred.
Performs quality improvement measures and processes in collaboration with the Case Management Department and Utilization Review Committee. Interprets medical information used in the processing of payments and claimsResponsibilities:Investigates denials by third party payers and crafts thorough appeals to justify medical necessity. Develop, establish, and implement uniform processes and procedures for the successful appeal of payer downgrades and denials in a manner that meets all payer requirements for accuracy and timeliness. Also ensures that appeals are managed within required timeframes for maximum reimbursement. Compiles reports. Prepares and assigns record review for Medical Staff Committees. Assists in determining data formatting and types of indicators and studies. Assist in staff education in preventing denials.Qualifications:Graduate from an accredited school of nursing preferred; baccalaureate degree preferred or > 5 years experience in an acute care facility with denials experience. Possesses both good oral and written communication skills. Demonstrated interpersonal relationships in a manner which enhances communication, promotes conflict resolution and facilitates staff development. Requires knowledge or understanding or integration or software and hardware. Demonstrates a willingness to learn new programs and obtain further education regarding computerization. Knowledge in ICD Coding preferred.