Department: Case ManagementAddress: Remote; applicant must reside in the state of Florida. Shift Details: Monday to Friday, 9 AM- 5 PMJackson Memorial Hospital is the flagship hospital for Jackson Health System and it has been a beacon of medical excellence and community care for more than a century. Throughout its rich and storied history, Jackson Memorial - located in the heart of the City of Miami - has been ground zero for some of the world's greatest medical breakthroughs and important moments in South Florida. We've grown into one of the nation's largest public hospitals, and one of the few that is also a world-class academic medical center with a proud mission and proven success. Jackson Memorial is an accredited, tertiary teaching hospital with 1,500 licensed beds, where nearly every medical specialty is provided by some of the world's most skilled and highly regarded multidisciplinary team of healthcare professionals.SummaryClinical Denials Coordinator is responsible for back up coverage within the entire Utilization Review team within Revenue Cycle which includes: Utilization Review within the (Emergency Dept area, Inpatient Utilization Review area, and all workflows within the Central Clearance Center functions as needed. Clinical Denials Coordinators are also responsible for reviewing denied accounts, establishing trends, identifying operational improvement opportunities, working with the impact areas to correct and improve weaknesses within their processes that leads to denials. Audit accounts as needed, and address clinical issues leading to denials. Work with payors on focused audits and coordinate the clinical audits. Work closely with the denial agencies on reporting and placements. Work with Utilization leadership on any assigned team projects.Responsibilities
- Audit denied or potentially denied accounts to determine true denial reason.
- Collaborate with denial agencies on identifying trends and reporting to denial committees.
- Work closely with payors and JHS managed care department and manage projects focused on resolving denials and improving recoveries.
- Coordinate denial committee meetings at each facility and ensure reviews and reports are completed timely and presented at each meeting.
- Assist the CBO in reconciling placements and recoveries monthly to ensure Siemens and Connance are in balance.
- Coordinate with CFO's and denial committee teams at each facility to ensure net denial targets are met.
- Crosstrain and assist with invoice reconciliation as needed.
- Assist with internal and external audit requests relating to denials as requested by management.
Experience
- Generally requires 3 to 5 years of related experience.
- At least one year of past payer experience specifically with utilization review, denials, audits, and/or appeals is highly preferred.
Education
- Bachelor's in Science required with a certification as a PA, LPN or RN.
- Master's degree preferred and/or certification as ARNP or Foreign Medical Graduate.
Credentials
- Valid PA, LPN or RN is preferred.
Jackson Health System is an equal opportunity employer and makes employment decisions without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, disability status, age, or any other status protected by law.