Demonstrates, through behavior, AdventHealth's core values of Integrity, Compassion, Balance, Excellence, Stewardship, and Teamwork.
Works closely with the Denial Prevention Manager, Manager of Medicare and Medicaid Collections, PFS Director and Utilization Management team to assess and strategize appeals and denial prevention for all regions.
Reviews EMR to develop appeal response and determine medical documentation necessary to respond to each denial at each level of appeal based on established criteria and the NCD/LCD requirements of CMS.
Works closely with all involved teams to exchange information regarding assignments, appeal statuses and next steps. Communicates to these teams regarding outside medical documentation required for all appeals at each level of appeal and what may be needed for any given appeal packet.
Works with HIM, PFS, and Denial Prevention teams to develop strategic plans for appeals and gather any necessary information from all departments involved to meet timely filing on all appeals/audits.
Discusses any cases with the Physician Advisors as required to establish a plan of appeal before they are taken to the ALJ or for any other appeal types that require Physician Advisor input.
Participates in any meetings, phone conferences or webinars as needed to either appeal cases or expand knowledge regarding CMS rule/regulations/appeal processes.
Serves as the Subject Matter Expert (SME) for clinical Medicare audits and appeals for all departments under the direction of the Manager of the Denial Prevention team.
Provides education to any group as requested to meet the needs of said group for Medicare audit/appeal education.
Analyzes data on audits and appeals, determines action plans as needed, reports back to appropriate stakeholders, and evaluates the efficacy of the plans that were put into place for best practice improvements.
KNOWLEDGE AND SKILLS REQUIRED:
Extensive knowledge of CMS LCD/NCD documentation.
Mastery of EMR data extrapolation.
Knowledge of all types of CMS audits and regulatory timelines
Understanding of the government auditor structure and/or how to research this information
Articulate in both written and verbal communication to formulate clear and concise arguments/rationale in clinical terms/language.
Critical thinking and problem-solving skills regarding clinical review, criteria, and response to the audit.
Ability to multi-task and work in a stressful and fast paced environment that has very tight timelines for work completion.
Experience with Medicare and/or Commercial appeals/denials.
KNOWLEDGE AND SKILLS PREFERRED:
Working knowledge of Excel, Word and Outlook
Past working experience with RAC Manager
EDUCATION AND EXPERIENCE REQUIRED:
Graduate of school of Nursing
Bachelor's degree in a field such as nursing, management, business
Minimum of three (3) years' experience as an RN in an acute clinical setting.
EDUCATION AND EXPERIENCE PREFERRED:
Previous experience appealing Medicare Audits
LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:
State of Florida current valid RN nursing license.
LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:
Certification specialty preferred in Utilization Management, managed care or other applicable professional certification.
This position will have oversight for the Medicare Review RN's that appeal all government audits and appeals
This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.
AdventHealth Greater Orlando (formerly Florida Hospital) is one of the largest faith-based health care providers in the United States. For 150 years, we have carried on a tradition of providing whole-person care that not only addresses patients' physical ailments, but also supports their emotional and spiritual well-being. We demonstrate the same level of compassion and care for our employees as well, doing all that we can to help them realize their full potential – both personally and professionally.