Denial Specialist/Lead Case Manager

Lee Health Fort Myers, FL
Ensures that reimbursement issues related to medical necessity are resolved to the best of his/her ability. Coordinates the System's proactive and retrospective denial management processes including but not limited to staff education, collaboration with payers, audits, data analysis, trend identification and improvement efforts. Serves as back up hospital clinical liaison to external review organizations with responsibility for monitoring, tracking and reporting changes, regulatory or otherwise, that impact reimbursement.

Requirements:

Education Requirements: Nursing Degree; bachelor's preferred

Experience Requirements: Minimum of 3 years clinical experience with required Utilization Review experience. Denials and appeal experience preferred.

State of Florida Licensure Requirements: Currently licensed or eligible for RN licensure in the State of Florida,

Certifications/Registration Requirements: Require Case Management Certification, ACM, CCM, CMCN or CPHM after 2 yrs. employment (time exception given for unsuccessful attempts)

Other: Communication and interpersonal skills, basic computer, analytical, grammar and spelling skills. Ability to effectively multi-task responsibilities.

General Requirements (has the ability to.) Sit - Continually ( i.e. Daily) Stand - Continually ( i.e. Daily) Walk - Continually ( i.e. Daily) Bend - Occasionally (i.e. Monthly) Climb - Occasionally (i.e. Monthly) Kneel - Occasionally (i.e. Monthly) Crouch - Occasionally (i.e. Monthly) Twist - Occasionally (i.e. Monthly) Sensory Requirements (has ability for.) Far Vision - Occasionally (i.e. Monthly) Near Vision - Continually ( i.e. Daily) Seeing Fine Details - Continually ( i.e. Daily) Hearing Norm Speech - Continually ( i.e. Daily) Hearing Overhead Pages - Continually ( i.e. Daily) Telephone use - Continually ( i.e. Daily) Mental & Emotional Requirements (ability to.) Cope with high level of stress - Continually ( i.e. Daily) Make decisions under high pressure - Continually ( i.e. Daily) Cope with anger/fear/hostility of others in a calm way - Continually ( i.e. Daily) Manage altercations - Continually ( i.e. Daily) Concentrate - Continually ( i.e. Daily) Handle a high degree of flexibility - Continually ( i.e. Daily) Handle multiple priorities in stressful situation - Continually ( i.e. Daily) Work alone - Continually ( i.e. Daily) Demonstrate high degree of patience - Continually ( i.e. Daily) Work in areas that are close and crowded - Continually ( i.e. Daily) Hand Manipulation (ability with.) Simple Grasping - Continually ( i.e. Daily) Firm Grasping - Occasionally (i.e. Monthly) Fine Manipulation - Occasionally (i.e. Monthly) Use of Keyboards - Continually ( i.e. Daily) Required Lifting (ability to lift.) Up to 10 lbs - Continually ( i.e. Daily) 11 to 24 lbs - Frequently ( i.e. Weekly) Pushing/Pulling (ability to push and pull.) Up to 10 lbs - Continually ( i.e. Daily) 11 to 24 lbs - Frequently ( i.e. Weekly) Environmental (may be exposed to.) Infectious Diseases - Continually ( i.e. Daily) Chemical Agents - Occasionally (i.e. Monthly) Dust, Fumes, Gases Occasionally (i.e. Monthly) Extremes in Temperature or Humidity - Occasionally (i.e. Monthly) Hazardous or Moving Equipment - Occasionally (i.e. Monthly) Loud Noises - Occasionally (i.e. Monthly)