Care Manager RN CMS Appeals

Day (United States of America)

900 WINDERLEY PL

MAITLAND

Florida

32751

Analyzes audit and appeal data, determines action plans, reports to stakeholders, and evaluates the efficacy of plans for best practice improvements. Prepares reports and presentations for Medicare-related meetings. Identifies and reports process improvements or gaps within the Revenue Cycle Medicare process to the Denial Prevention Manager. Collaborates 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 electronic medical records (EMR) to develop appeal responses and determine necessary medical documentation for each level of appeal based on established criteria and CMS requirements. Communicates with involved teams regarding assignments, appeal statuses, and next steps, ensuring timely exchange of information. Coordinates with HIM, PFS, and Denial Prevention teams to develop strategic plans for appeals and gather necessary information to meet timely filing requirements. Reviews and discusses cases with Physician Advisors to establish plans of action for appeals. Participates in meetings, phone conferences, or webinars to appeal cases and expand knowledge of CMS rules, regulations, and appeal processes. Tracks and trends Medicare accounts within OnTarget Revenue, analyzing data and reporting findings. Serves as the Subject Matter Expert (SME) for clinical Medicare audits and appeals, providing guidance to all departments. Develops and implements educational materials for Medicare audit and appeal education as needed. Other duties as assigned.Knowledge, Skills, and Abilities:
• Proficient use and knowledge CMS LCD/NCD documentation. [Required]
• Excellence/Proficiency with CMS/First Coast web platforms [Required]
• Effective oral and written communication skills, with the ability to articulate complex information in understandable terms to all levels of staff.
• Mastery of EMR data extrapolation [Required]
• Experience in Utilization Management or Denial Management [Required]
• Knowledge of all types of CMS audits and regulatory timelines [Required]
• Understanding of the government auditor structure and/or how to research this information [Required]
• Utilizes critical thinking skills in the performance of their duties. Supports the planning, organizing, and leading through application of critical thinking skills. Utilizes data driven decision making, incorporating evidence into the decision process. [Required]
• Ability to multi-task and work in a stressful and fast paced environment that has very tight timelines for work completion. [Required]
• Work independently with minimal supervision. [Required]
• Experience with Medicare and/or Commercial appeals/denials. [Required]
• Excellent social or clinical practice knowledge and can apply the knowledge to development and delivery of OnTarget Revenue education. [Required]
• Acts as a role model for professionalism for the Denial Prevention Medicare team. [Required]
• Working knowledge of Excel, Word and Outlook [Preferred]
• Past working experience with RAC Manager [Preferred]

Education:
• Associate's of Nursing [Required]
• Bachelor's of Nursing [Preferred]
• Master's of Nursing [Preferred]

Field of Study:
• N/A

Work Experience:
• 2+ experience as an RN in an acute clinical setting [Required]
• Medicare Appeals [Required]
• Previous eSolutions experience [Preferred]

Additional Information:
• N/A

Licenses and Certifications:
• Registered Nurse (RN) [Required]

Physical Requirements: (Please click the link below to view work requirements)
Physical Requirements - https://tinyurl.com/msy4mja2

$65,582.40 - $108,646.85