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Cedars-Sinai Registered Nurse - Denials Management Program Coordinator in Los Angeles, California

Are you ready to bring your expert clinical skills to a

world-class facility recognized as one of the top ten in the United States? Do

you have a passion for the highest quality and patient happiness? Then please

respond to this dynamic opportunity available with one of the best places to

work in Southern California! We would be happy to hear from you.

When the work you do every single day has a crucial impact

on the lives of others, every effort, every detail, and every second matters.

This shared culture of happiness, passion and dedication pulses through

Cedars-Sinai, and it’s just one of the many reasons we’ve achieved our fifth

consecutive Magnet designation for nursing excellence. From working with a team

of dedicated healthcare professionals to using state-of-the-art facilities,

you’ll have everything needed to do something incredible—for yourself, and for

others. Join us, and discover why U.S. News & World Report has named us one

of America’s Best Hospitals.

As a Denials Management Program Coordinator, you will be

responsible for overall management and communication of clinically based

appeals between Cedars-Sinai and outside payers. You will also act as a liaison

and point of contact to/for division and other internal representatives for

denial and appeal inquiries. In addition, you will actively manage, maintain

and communicate to the Manager regarding trends, and recommended corrective

action plans.

  • Supports Manager in theresponse process for the organization on all government audits.

  • Writes reviews and ensuresresponses are complete and delivered in a timely manner. These includeresponses to all applicable entities.

  • Reviews non-governmentdenials and determines appropriateness of denial based upon applicableguidelines, professional judgment, and/or community standards and respondsas per department policy.

  • Identification andfacilitation of educational opportunities with other departments,providers, and payers to decrease denials and improve quality of serviceto patients.

  • Conduct informal andformal education programs within the organization.

  • Works in collaborationwith internal contacts and health plans to develop corrective action plansto address identified trends in reasons for denials.

  • Utilizes electronicdatabase to track reasons for denial, result of denial review as itrelates to ability to appeal, date of appeal actions, outcome of appeal ifappropriate.

  • Performs case managementreview of issues related to compliance with government payer coverageissues as well as commercial denials.

  • Provides oversight of thepatient classification programs, including but not limited to thepre-procedure review program and applicable vendors, and engagement.

Education:

  • Graduate of an accredited nursing program required

  • BSN preferred

License/Certification:

  • Current, unrestricted California RN License required

  • BLS from the American Heart Association required

  • Case Management certification (CCM or ACM) required or willing to obtain within one year from start date

Experience:

  • A minimum of 1 year of acute care nursing experience required

  • Experience in ER, Telemetry, ICU or Cath Lab preferred

  • 6 months of case management experience preferred

  • Minimum required computer competency comprised of a working knowledge of Windows or comparable system (specifically including keyboarding and mouse skills), as well as word processing, spreadsheets, presentation development, e-mail, browsers, and online reporting

Keywords: Case Manager, Case Management, Utilization Review, Appeals, Denials, Insurance, Healthcare, Medical, Hospital, Los Angeles, CA, California

Cedars-Sinai is an EEO employer. Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law.

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