Denial and Appeals Coordinator Full Time

Description

San Diego Area

At ScionHealth, we empower our caregivers to do what they do best. We value every voice by caring deeply for every patient and each other. We show courage by running toward the challenge and we lean into new ideas by embracing curiosity and question asking. Together, we create our culture by living our values in our day-to-day interactions with our patients and teammates.

Job Summary

The Denials & Appeals Coordinator serves as the operational driver for timely and effective denial management, working closely with other members of the team, especially utilization management, to ensure no step is missed in preventing and resolving authorization-related denials. While not a clinical role, this position is critical in executing the processes that protect revenue and keep patient care moving forward. Focused on denial prevention, the Denials & Appeals Coordinator monitors the concurrent review process for continued stay authorizations, tracking potential issues and ensuring timely follow-up for designated facilities. This role actively tracks, organizes, and reports denial activity, partnering with case management teams, the Centralized Business Office, managed care, facility controllers, Clinical Denials Management, and Regional leadership to ensure alignment and swift resolution. By acting as a central point of coordination and follow-through, the Denials & Appeals Coordinator turns strategy into action-ensuring tasks are completed, deadlines are met, and communication flows between all parties. This role demonstrates accountability, attention to detail, and a commitment to quality improvement, problem solving, and productivity enhancement in an interdisciplinary model.

Essential Functions

• Serves as key team member of the new Central Access and Authorizations Team (CAAT), serving as a subject matter expert on denial prevention and coordination.

• Works with facility to gather clinical information from medical record. Responsibility may include printing and scanning into required systems.

• Ensures all denial-related documentation is complete, accurate, and submitted within required timeframes

• Collaborates with other members of the CAAT, Business Development, Case Management, and Clinical Teams in denial management process

• Coordinates and schedules peer to peer physician consults as needed; may work with case management if attending physician is completing peer to peer, or may work directly with physician advisory group to schedule

• Monitors and tracks insurance denials; identify trends in the data

• Communicates authorization outcomes to appropriate personnel (hospital and Centralized Business Office)

• Manage the denial root cause analysis efforts as requested; including

• Capturing lessons learned

• Identifying training opportunities

• Providing appropriate communication and follow up to the teams

• Monitors concurrent review processes for continued stay authorizations to identify potential denial risks

• Serves as an additional layer of support in the denials management process:

• Compiles data for analysis of trends and opportunities by hospital, payer, or Region

• Monitors and tracks total certified days for managed payers (commercial, managed government and Medicaid) and communicates missing certifications to hospital personnel

• Identifies trends and opportunities with specific facilities, payors, and staff members related to the concurrent review process and denials

• Compiles and communicates reports for facility and leaders on denial trends for continuous improvement opportunities

• Support ongoing analytics and data reporting requirements

• Maintains working knowledge of government and non-government payor practices, regulations, standards and reimbursement.

• Maintains clinical knowledge to support the utilization management team

• Participates in continuing education/ professional development activities

• Learns and develops full knowledge of the CAAT Admission Processes and actively seeks to continously improve them

• Learns and has a full understanding of scheduling and pre-register routines in Meditech and any other referral platform utilized by the CAAT team (i.e., Referral Manager)

• And ad hoc duties as assigned that fall within scope of the CAAT team

Knowledge/Skills/Abilities/Expectations

• Team player, able to communicate and demonstrate a professional image/attitude
• Excellent oral and written communication and interpersonal skills
• Strong computer skills with both standard and proprietary applications
• Data entry with attention to detail
• Conducts job responsibilities in accordance with the standards set out in the Company's Code of Business Conduct, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards
• Communicates and demonstrates a professional image/attitude for patients, families, clients, coworkers and other
• Adheres to policies and practices of ScionHealth
• Must read, write, and speak fluent English
• Must have good and regular attendance
• Will report to a building; may cover more than one building depending on market alignment and structure
• Approximate percent of time required to travel: N/A

Pay Range: $20.62-$30.93/hr.

ScionHealth has a comprehensive benefits package for benefit-eligible employees that includes Medical, Dental, Vision, 401(k), FSA/HSA, Life Insurance, Paid Time Off, and Wellness.

Qualifications

Education

• High School Diploma or GED required, Associates or Bachelors Degree preferred;
• preference towards a healthcare related area of concentration or be a licensed health care provider or equivalent experience.

Licenses/Certifications

• None Required

Experience

• 2+ years of healthcare experience.
• Experience in case management, medical records, billing, utilization review or admissions a plus.
• Post-acute care and long-term acute care experience a plus.