Denial & Appeals Coordinator, RN, Concurrent Denials Prevention

Baptist Health

. Function as a senior expert consultant for Case Management .

Posted 9/25/2026full-timeRemote • Florida • United StatesMid-LevelSenior💰 $89,523 - $119,066 per yearWebsite

About the role

Key responsibilities & impact

Function as a senior expert consultant for Case Management
Ensure high-quality patient care, appropriate ALOS, efficient resource utilization, and appropriate medical necessity for expected reimbursement
Evaluate denials and non-certified days from third-party payors for appropriateness and appeal feasibility
Consult with attending physicians, physician advisors, and case managers to formulate secondary and written formal appeals
Use MCG, InterQual, and CMS guidelines for medical necessity determinations
Serve as expert internal consultant to HSS, PFS, Compliance, Surgery, Transfer Center, and other departments on regulatory and billing requirements
Act as liaison between the hospital and eQ Health, CMS, MAC, QIO, ALJ, Medicare Council, and RAC
Prepare appeals for applicable regulatory and review entities
Review all surgery cases across BHSF before and after procedures for appropriate CPT, level of care, relevant testing, authorization, and medical necessity in the EMR prior to billing
Make billing recommendations for medical and surgical accounts based on payor

Requirements

What you’ll need

Bachelor's degree required, with an exception for RNs hired prior to 2/2012 with an Associate's Degree in Nursing who must complete the BSN within 3 years of hire
RN license and one of the listed certifications required
4 years minimum required experience
2 years of hospital or payor Utilization management review experience required
3 years of hospital clinical experience preferred
ACMA ACM Certification, CCMC Case Manager, AACN Acute/Critical Care Nursing, ABMCM Certified Managed Care Nurse, AAMCN Utilization Review Professionals, MCG, ANCC Nursing Case Management, or ACMA Case Management Administrator Certification
Excellent written, interpersonal communication, and negotiation skills
Strong critical thinking and ability to perform clinical chart review and abstract information efficiently
Strong analytical, data management, and computer skills, including Word and Excel
Strong organizational and time management skills, with ability to prioritize multiple tasks and role components
Current working knowledge of payor and managed care reimbursement preferred
Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families
Knowledge of local, state, and federal legislation and regulations
Ability to tolerate high-volume production standards
MCG Certification or eligibility to pursue it within 90 days of hire
Case management, utilization review, or surgery pre-anesthesia experience preferred
Familiarity with CPT, ICD-9, ICD-10, and DRG coding preferred
Strong ability to research evidence-based practices

Benefits

Comp & perks

Career growth and development opportunities, with clear pathways and ongoing support
Comprehensive health and wellness resources that go beyond traditional benefits
Wellness program that can help employees eliminate their medical plan deductible, reducing out-of-pocket healthcare costs
Tuition reimbursement to support continued learning and advancement