As Mount Sinai grows, so does our legacy in high-quality health care. Since 1949, Mount Sinai Medical Center has remained committed to providing access to its diverse community. In delivering an unmatched level of clinical expertise, our medical center is committed to recruiting and training top healthcare workers from across the country. We offer the latest in advanced medicine, technology, and comfort in 12 facilities across Miami-Dade (including our 674-bed main campus facility) and Monroe Counties, with 38 medical services, including cancer care, 24/7 emergency care, orthopedics, cardiovascular care, and more. Mount Sinai takes pride in being South Florida's largest private independent not-for-profit hospital, dedicated to continuing the training of the next generation of medical pioneers. Culture of Caring: The Sinai Way Our hardworking, tight-knit community of more than 4,000 dedicated employees fosters an environment of care and compassion. Each member plays a vital role in our collective mission to deliver excellent healthcare through innovation, education, and research. At Mount Sinai, we take pride in our achievements, aiming to be a beacon of quality healthcare in South Florida. We welcome all healthcare professionals to join our thriving community and contribute to our pursuit for clinical excellence. Department: CC019040 Patient Accounting

Job Description

Summary: The Sr. Clinical Denials Coordinator serves as a Clinical Denials Unit Reviewer responsible for managing and appealing level-of-care and medical necessity denials. This role applies clinical judgment, payer policy knowledge, InterQual criteria, and contract language to construct high-quality appeals and optimize reimbursement outcomes. Conducts clinical appeals for level of care medical necessity denials.Position Responsibilities

• Communicates effectively with Business Office and Care Management teams in order to draw all necessary information and assess best course of action.
• Has command of InterQual criteria and can navigate application efficiently.
• Is familiar with contracts and can discern what contract language means, which language clauses are relevant to her reviews and correctly applies these into her appeals and/or conclusions.
• Constructs well-redacted, concise and eloquent appeals, with rationales that are supported with as much clinical data/evidence as possible.
• Has appropriate command of clinical concepts and is competent performing clinical chart reviews.
• Periodically follows up on cases, appeals pending decisions, and updates data within reporting tool accurately and in a timely basis.
• Escalates unfavorable cases that may need Peer-to-peer review and ensures all appeal options are exhausted.
• Maintains productivity rate of 5-10 daily appeals or as otherwise agreed with management.
• Familiar navigating all necessary applications to complete duties including Epic Hospital Billing, Epic Doc Review, MoreCare, OneContent, InterQual, Availity, Optum, other payor portals, etc.
• Is familiar with Payor's policies and appeals process and ensures appeals are completed timely.
• Maintains reporting tool that can effectively track program's outcomes.
• Identifies trends and reports to management, including recommendations for corrective action.
• All other tasks as assigned.

Qualifications

• License/Registration/Certification
• RN License preferred.
• Education
• Medical School Graduate/Bachelor's Degree required.
• Experience
• Critical Care/ Surgery/ Intensive Care patient care experience or two years prior experience in case management, clinical denials appeals/ utilization management or related field.

Benefits: We believe in the physical and mental well-being of our employees and are committed to offering comprehensive benefits that fit their personal needs:

• Health benefits
• Life insurance
• Long-term disability coverage
• Healthcare spending accounts
• Retirement plan
• Paid time off
• Pet Insurance
• Tuition reimbursement
• Employee assistance program
• Wellness program
• On-site housing for select positions and more!

Degree Requirements: Certification: