St. Mary's Medical Center is seeking a Denials and Appeals Specialist who exercises independent judgment and professional discretion in the practice of care management to a select group of patients. They collaborate with URS and physicians to ensure that patients are at the appropriate level of care with the use of clinical based guidelines such as InterQual and MCG. The Denials and Appeals Specialist provides necessary documentation for appeal of denials and provides updates to the billing department of the denial/appeal statuses. They utilize collaborative problem-solving skills to meet the needs of the patients and physicians while meeting the contractual guidelines of our payers.
QualificationsEDUCATION:
Graduate of an approved School of Nursing. Current licensure as a Registered Nurse (RN) in the state of West Virginia or a valid compact state nurse license. BSN, master’s degree preferred, not required.
CERTIFICATION/SKILLS:
Working knowledge of medical terminology. Excellent communication skills-verbal and written ability to work with patients, families, physicians, and other hospital departments. BLS required.
EXPERIENCE:
Five years nursing experience. Minimum experience includes patient care in the hospital setting, direct knowledge of care management, discharge planning and resource management.
