Job Description:

Location:

Miramar, Florida


We have an outstanding reputation for providing patient- and family-centered care that exceeds all expectations. Together, we have created an award-winning, nationally-recognized system where every effort is focused on delivering Deeper Caring and Smarter Healthcare throughout our communities. Career opportunities exist on diverse teams across our many facilities where you can search open positions and apply online to join #teamMHSflorida.


Learn more below.



Summary:



Completes appeal documents based on medical necessity and appropriateness of services in response to denials and underpayments received from managed care plans.


InterQual REQUIRED
EPIC preferred



Responsibilities:



Prepares documents on unresolved cases and participates in meetings with clinical personnel from managed care companies to address cases.Assists with questions related to denials or underpayments concerning readmissions, coding, accuracy of charges, and/or duplication of services.Reviews documentation from medical chart and applies clinical guidelines, regulations and/or payor contract terms to support medical necessity and appropriateness of services rendered. Formulates written document with findings to be used to assist with overturning denials.Reviews and takes action on denials received from managed care payors while patient is still inhouse. Communicates directly with designees from managed care payors and/or internal departments to provide additional information to be evaluated to overturn denial.



Competencies:



ACCOUNTABILITY, ANALYSIS AND DECISION MAKING, CLINICAL POLICIES AND STANDARDS, CUSTOMER SERVICE, DEVELOPS RELATIONSHIPS, EFFECTIVE COMMUNICATION, RESPONDING TO CHANGE, STANDARDS OF BEHAVIOR, TEAM WORK



Education and Certification Requirements:



Accredited Program: Nursing (Required)Registered Nurse Compact License (RN LICENSE COMPACT) - Compact RN Multistate, Registered Nurse License (RN LICENSE) - State of Florida (FL)



Additional Job Information:



Complexity of Work: Requires effective critical thinking skills, effective communication skills and decisive judgement. Must be able to make decisions and take appropriate action with minimal supervision. Requires knowledge with ability to apply Interqual, MCG Guidelines and/or state and federal regulations and statutes related to evaluating necessity of medical services. Working knowledge of managed care and managed care contract terminology. Intermediate level knowledge of Microsoft Word and basic level knowledge of Microsoft Excel. Required Work Experience: 3 years clinical nursing experience in a hospital setting or clinical area of insurance company. Demonstrated ability to analyze and apply clinical criteria to decision making required.



Working Conditions and Physical Requirements:

• Bending and Stooping = 0%


• Climbing = 0%


• Keyboard Entry = 80%


• Kneeling = 0%


• Lifting/Carrying Patients 35 Pounds or Greater = 0%


• Lifting or Carrying 0 - 25 lbs Non-Patient = 0%


• Lifting or Carrying 2501 lbs - 75 lbs Non-Patient = 0%


• Lifting or Carrying > 75 lbs Non-Patient = 0%


• Pushing or Pulling 0 - 25 lbs Non-Patient = 0%


• Pushing or Pulling 26 - 75 lbs Non-Patient = 0%


• Pushing or Pulling > 75 lbs Non-Patient = 0%


• Reaching = 0%


• Repetitive Movement Foot/Leg = 0%


• Repetitive Movement Hand/Arm = 80%


• Running = 0%


• Sitting = 80%


• Squatting = 0%


• Standing = 80%


• Walking = 80%


• Audible Speech = 80%


• Hearing Acuity = 80%


• Smelling Acuity = 0%


• Taste Discrimination = 0%


• Depth Perception = 80%


• Distinguish Color = 80%


• Seeing - Far = 80%


• Seeing - Near = 80%


• Bio hazardous Waste = 0%


• Biological Hazards - Respiratory = 0%


• Biological Hazards - Skin or Ingestion = 0%


• Blood and/or Bodily Fluids = 0%


• Communicable Diseases and/or Pathogens = 0%


• Asbestos = 0%


• Cytotoxic Chemicals = 0%


• Dust = 0%


• Gas/Vapors/Fumes = 0%


• Hazardous Chemicals = 0%


• Hazardous Medication = 0%


• Latex = 0%


• Computer Monitor = 80%


• Domestic Animals = 0%


• Extreme Heat/Cold = 0%


• Fire Risk = 0%


• Hazardous Noise = 0%


• Heating Devices = 0%


• Hypoxia = 0%


• Laser/High Intensity Lights = 0%


• Magnetic Fields = 0%


• Moving Mechanical Parts = 0%


• Needles/Sharp Objects = 0%


• Potential Electric Shock = 0%


• Potential for Physical Assault = 0%


• Radiation = 0%


• Sudden Decompression During Flights = 0%


• Unprotected Heights = 0%


• Wet or Slippery Surfaces = 0%

Shift:



Primarily for office workers - not eligible for shift differential



Disclaimer: This job description is not intended, nor should it be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job. It is intended to indicate the general nature and level of work performed by employees within this classification.


Wages shown on independent job boards reflect market averages, not specific to any employer. We encourage candidates to talk to their Memorial Healthcare System recruiter to discuss actual pay rates, during the hiring process.


Memorial Healthcare System is proud to be an equal opportunity employer committed to workplace diversity.


Memorial Healthcare System recruits, hires and promotes qualified candidates for employment opportunities without regard to race, color, age, religion, gender, gender identity or expression, sexual orientation, national origin, veteran status, disability, genetic information, or any factor prohibited by law.


We are proud to offer Veteran's Preference to former military, reservists and military spouses (including widows and widowers). You must indicate your status on your application to take advantage of this program.


Employment is subject to post offer, pre-placement assessment, including drug testing.


If you need reasonable accommodation during the application process, please call 954-276-8340 (M-F, 8am-5pm) or email TalentAcquisitionCenter@mhs.net Apply Now