Baptist Health is the region’s largest not-for-profit healthcare organization, with 12 hospitals, over 28,000 employees, 4,500 physicians and 200 outpatient centers, urgent care facilities and physician practices across Miami-Dade, Monroe, Broward and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, Baptist Health is supported by philanthropy and driven by its faith-based mission of medical excellence. For 25 years, we’ve been named one of Fortune’s 100 Best Companies to Work For, and in the 2024-2025 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 45 high-performing honors. 

What truly sets us apart is our people. At Baptist Health, we create personal connections with our colleagues that go beyond the workplace, and we form meaningful relationships with patients and their families that extend beyond delivering care. Many of us have walked in our patients’ shoes ourselves and that shared experience fuels out commitment to compassion and quality. Our culture is rooted in purpose, and every team member plays a part in making a positive impact – because when it comes to caring for people, we’re all in.

Description:

Functions as a senior expert consultant for Case Management to ensure high quality patient care, appropriate ALOS, efficient resource utilization, application of regulatory and national guidelines to ensure medical necessity is appropriate for expected reimbursement. Evaluates denials and non-certified days from 3rd party payors to determine appropriateness of denial and feasibility of appeal. Consults with attending physician, physician advisor, and case managers to formulate secondary appeals and written formal appeals using appropriate medical management tools for medical necessity determination ( MCG/Interqual/ CMS guidelines). Serves as the expert internal consultant for multiple departments (HSS, PFS, Compliance, Surgery, Transfer Center, etc.) related to regulatory and billing requirements (LCD/NCD/EBC criteria). Serves as liaison between hospital and eQ health, CMS and when appropriate their Contractors such as the MAC, QIO, ALJ, Medicare Council, and the RAC and prepares appeals for all of the above. Reviews all surgery cases across BHSF pre and post procedure to ensure appropriate CPT, LOC, Relevant testing, authorization and medical necessity is present in the EMR prior to billing. Makes billing recommendation for all medical and surgical accounts as applicable by payor
Estimated salary range for this position is $87755.20 - $116714.42 / year depending on experience.

Qualifications:

Degrees:

• Bachelors.

Licenses & Certifications:

• AAMCN Utilization Review Professionals.
• AACN Acute/Critical Care Nursing (Adult, Pediatric & Neonatal).
• MCG.
• ABMCM Certified Managed Care Nurse.
• ACMA Case Management Administrator Certification.
• CCMC Case Manager.
• ACMA ACM Certification.
• ANCC Nursing Case Management.
• Registered Nurse.

Additional Qualifications:

• RNs hired prior to 2/2012 with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN, however,they are required to complete the BSN within 3 years of hire.
• RN license & one of the listed certifications is required.
• 3 years of hospital clinical experience preferred & 2 years of hospital or payor Utilization management review experience required.
• Excellent written, interpersonal communication & negotiation skills.
• Strong critical thinking skills & the ability to perform clinical chart review abstract information efficiently.
• Strong analytical,data management & computer skills/Word /Excel.
• Strong organizational & time management skills,as evidenced by capacity to prioritize multiple tasks & role components.
• Current working knowledge of payor & managed care reimbursement preferred.
• Ability to work independently & exercise sound judgment in interactions with the health care team & patients/families.
• Knowledgeable in local, state, & federal legislation & regulations.
• Ability to tolerate high volume production st&ards.
• MCG Certification or eligible to pursue within 90 days of hire.
• Case management,utilization review/surgery pre-anesthesia experience preferred.
• Familiar with CPT, ICD-9 &-10 & DRG coding preferred.
• Strong ability to research evidence-based practices.

Minimum Required Experience:
4 Years

EOE, including disability/vets