Job Description

RN, Appeals Coordinator

Support Department: Case Management

Management: No

Schedule: Full-Time 08:00am-16:30pm

Reports To: Director of Case Management

Summary: Under the direction of Utilization Review/Case Management, the Appeals Coordinator is responsible for overall management and communication of clinically based appeals between C.S.M.C. and outside payers. Act as a liaison and point of contact to/for Utilization Review, Case Management and other C.S.M.C. representatives for denial and appeal inquiries. In addition will actively manage, maintain and communication to appropriate stakeholders denial and appeal activities, trends, and recommended corrective action plans.

Requirements: Associates Degree required, Bachelor's Degree in a Healthcare related field preferred. Four (4) years Case Management experience in an acute care setting required. Four (4) years commercial/government denials and appeals experience preferred. Current California RN license required. Certified Case Management RN preferred.  Recent sound clinical knowledge; knowledge of medical literature, research methodology, healthcare delivery systems, financial/reimbursement issues, and Medical Center/Medical Staff organizations.  Must possess a minimum computer competency comprised of a working knowledge of Windows or comparable system (specifically including keyboarding and mouse skills). As applicable to individual job duties and expectations, employee must additionally possess a working knowledge of word processing, spreadsheets, presentation development, e-mail, browsers, and online reporting.