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Denials & Appeals Administrator (RN)
Boston Medical Center (BMC) is more than a hospital. Its a network of support and care that touches the lives of hundreds of thousands of people in need each year. It is the largest and busiest provider of trauma and emergency services in New England. Emphasizing community-based care, BMC is committed to providing consistently excellent and accessible health services to all-and is the largest safety-net hospital in New England. The hospital is also the primary teaching affiliate of the nationally ranked Boston University School of Medicine (BUSM) and a founding partner of Boston HealthNet - an integrated health care delivery systems that includes many community health centers. Join BMC today and help us achieve our Vision 2030 which is a long-term goal to make Boston the healthiest urban population in the world.
Position: Program Coordinator - Vital Village
Department: Denials Access
Schedule: Per Diem
POSITION SUMMARY:
The RN Appeal Administrator will be responsible for the Pre-denial/ Denial and appeal process in addition to Utilization Review, to validate the patient's placement to be at the most appropriate level of care based on nationally accepted admission criteria. The Appeal/ UR Administrator uses medical necessity screening tools, such as InterQual or MCG criteria, to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient's expected length of stay. The The Appeal/ UR Administrator secures authorization for the patient's clinical services through timely collaboration and communication with payers as required. The Appeal/ UR Administrator follows the UR process, in addition to the pre-denial and denial/appeal process as defined in the attached job description and in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review.
JOB REQUIREMENT
5 + years of Care Management and/or UM experience required.
EDUCATION:
*MA RN License
*RN, ASN/BSN
*CCM preferred
Equal Opportunity Employer/Disabled/Veterans
Boston Medical Center’s policy is to ensure equal employment opportunities for all, without regard to race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic. We view the principle of equal employment opportunity as a vital element in the employment process and as a hallmark of good management.
BMC is an equal employment/affirmative action employer. If you need accommodation for any part of the application process because of a medical condition or disability, please send an e-mail to Talentacquisition@bmc.org or call 617-638-8582 to let us know the nature of your request.