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Clinical Appeals Coordinator

Job ID 84575 Date posted 11/28/2017
  • Facility: Sharp HealthCare
  • City: San Diego
  • Department: System Integrated Care Mgmt
  • Category: Specialty Nurse Jobs
  • Job Status: Full-Time
  • Shift: Day Job
  • FTE: 1.0
  • Shift Start: 8 AM
  • Shift End Time: 4:30 PM
This position is located in Kearny Mesa, CA (San Diego County)
8 hour shift, Full-time, 8:00am - 4:30pm, working weekends as needed
Required Skills and Qualifications
  • 3 years clinical experience (acute care/hospital)
  • 3 years’ experience case management, utilization review, denial management, audits and appeals, clinical documentation improvement or related experience
  • Highly developed verbal, written and interpersonal communication skills
  • Ability to effectively and accurately manage multiple tasks and complex projects in a fast-paced and changing environment
  • Ability to effectively manage physician relationships
  • Ability to work independently with minimal supervision
  • Discretion when dealing with sensitive information
  • Ability to analyze and apply complex regulations
  • Proficient in computer applications including MS Office, Excel and PowerPoint
  • Experience working with electronic health record
Preferred Skills and Qualifications
  • Current, unencumbered California RN license strongly desired
  • BS degree - RN
  • Experience working with payer environment
  • Working knowledge of medical necessity criteria
  • Certified Case Manager (CCM)
  • Accredited Case Manager (ACM)
  • Certified Professional in Healthcare Quality (CPHQ)
  • Certified Professional in Healthcare Management (CPHM)

The Clinical Appeals Coordinator will be responsible for developing the organization responses to denials, audits and appeals for government (particularly CMS recovery Audit Contractor) improper payment initiatives, as well as commercial payers. The Clinical Appeals Coordinator will also be responsible for risk mitigation and assist with plans of correction, and action plans, as well as education as needed. The coordinator will work closely with Case Management, Patient Access Services, Patient Financial Services, and physicians in key roles (Physician Advisor, Chief Medical Officer).
The Clinical Appeals Coordinator position is part of the System Integrated Care Management Department.  The Clinical Appeals Coordinator is under the System Director of Case Management Projects and Technology. The System Integrated Care Management (ICM) department is located at our Sharp Spectrum office and services the Sharp System.  The ICM Department consists of RN Clinical Appeals Coordinators, a clerical assistant and a part-time Physician Advisor.  We seek detail-oriented team players with critical thinking skills and the ability to think outside the box and handle competing priorities to join our dedicated and seasoned team.
Sharp System Services have campuses located in the communities of Kearny Mesa and Serra Mesa and consist of the Spectrum location, the Ruffin Road location and Sharp Operations Center (SOC). These offices provide the centralized integrated system support services to the operating entities within the system. These services include: Strategic Planning, Business Development, Information Technology, Compliance, Internal Audit, Legal, Risk Management and Insurance, Contracts, Human Resources, Facilities Management and Development, Clinical Effectiveness, Finance, Nursing, Systems Supply Chain Services, Marketing and Communications, The Sharp Experience and Sharp University.
Essential Physical Requirements of position may be discussed during interview.
Sharp HealthCare is proud to be an Equal Opportunity/Affirmative Action Employer.  All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, gender identity, transgender status, sexual orientation, protected veteran status or any other protected class.
Keyword:  Clinical Appeals Coordinator Jobs, Case Manager Jobs, RN Case Management Jobs, Utilization Review Jobs, Denial Management Jobs, Appeals Jobs, Audits, Quality, CCM, ACM, CPHQ, CPHM, Nursing Jobs, RN Jobs, San Diego Jobs

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