Denial & Appeals Coordinator, RN – Concurrent Denials Prevention

Baptist Health

. Functions as a senior expert consultant for Case Management to ensure high quality patient care, appropriate ALOS, efficient resource utilization, and appropriate application of regulatory and national guidelines .

Posted 11/10/2026full-timeRemote • Florida • United StatesMid-LevelSenior💰 $89,523 - $119,066 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Case Management, ensuring high-quality patient care and compliance with regulatory guidelines. Proficient in evaluating denials, preparing appeals, and collaborating with healthcare teams to optimize resource utilization and patient outcomes.

Highest-signal resume keywords

RN LicenseUtilization Management Review ExperienceMCG CertificationCPT and ICD Coding KnowledgeStrong Analytical Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Chart ReviewData ManagementEvidence-Based ResearchBilling RecommendationsRegulatory Compliance

Soft Skills

Excellent Written CommunicationInterpersonal CommunicationNegotiation SkillsOrganizational SkillsTime Management Skills

Tools & Technologies

EMR SystemsWordExcel

Certifications & Qualifications

ACMA ACM CertificationCCMC Case ManagerAACN Acute/Critical Care NursingABMCM Certified Managed Care NurseAAMCN Utilization Review Professionals

Industry Keywords

Case ManagementUtilization ReviewManaged Care ReimbursementLCD/NCD/EBC CriteriaCMS Guidelines

About the role

Key responsibilities & impact

Functions as a senior expert consultant for Case Management to ensure high quality patient care, appropriate ALOS, efficient resource utilization, and appropriate application of regulatory and national guidelines
Evaluates denials and non-certified days from third-party payors to determine appropriateness of denial and feasibility of appeal
Consults with attending physicians, physician advisors, and case managers to formulate secondary and formal written appeals using MCG, InterQual, and CMS guidelines
Serves as expert internal consultant for HSS, PFS, Compliance, Surgery, Transfer Center, and other departments regarding regulatory and billing requirements, including LCD/NCD/EBC criteria
Serves as liaison between the hospital and eQ health, CMS, MAC, QIO, ALJ, Medicare Council, and RAC
Prepares appeals for applicable regulatory and payer entities
Reviews all surgery cases across BHSF before and after procedures to ensure appropriate CPT, level of care, relevant testing, authorization, and medical necessity are documented in the EMR before billing
Makes billing recommendations for medical and surgical accounts according to payer

Requirements

What you’ll need

Bachelor's degree
RN license and one of the listed certifications is required
4 years minimum required experience
2 years of hospital or payor Utilization management review experience required
RNs hired prior to 2/2012 with an Associates Degree in Nursing must complete the BSN within 3 years of hire
Excellent written, interpersonal communication and negotiation skills
Strong critical thinking skills 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 capacity to prioritize multiple tasks and role components
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 within 90 days of hire
Strong ability to research evidence-based practices
3 years of hospital clinical experience preferred
Current working knowledge of payor and managed care reimbursement preferred
Case management, utilization review/surgery pre-anesthesia experience preferred
Familiarity with CPT, ICD-9 and ICD-10, and DRG coding preferred
One of the listed certifications: ACMA ACM Certification; CCMC Case Manager; AACN Acute/Critical Care Nursing (Adult, Pediatric & Neonatal); ABMCM Certified Managed Care Nurse; AAMCN Utilization Review Professionals; MCG; ANCC Nursing Case Management; ACMA Case Management Administrator Certification

Benefits

Comp & perks

Career growth and development opportunities, with clear pathways and ongoing support
Comprehensive health and wellness resources that go beyond traditional benefits
A 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