Beacon Health System

Summary

The Denials and Appeals Coordinator serves as a critical liaison between Beacon Health System, physicians, third-party payors, and auditors to ensure timely and accurate communication regarding medical necessity and reimbursement. This role is responsible for managing and coordinating the appeal process for denied hospitalizations by reviewing medical records, preparing appeal documentation, and identifying denial trends to support proactive resolution. The Coordinator plays an essential role in protecting revenue and improving the efficiency of the revenue cycle while upholding patient confidentiality.

Key Responsibilities

Denials Management & Appeals Coordination

• Coordinate all aspects of the denial and appeal process for inpatient hospitalizations.
• Maintain an efficient workflow for data requests, responses, and related correspondence with payors and review agencies.
• Review denied claims for medical necessity and documentation adequacy, preparing and submitting appeal letters to support reimbursement.
• Arrange and facilitate peer-to-peer reviews between insurance Medical Directors and Attending Physicians.
• Monitor and analyze denial trends using internal databases; identify preventable causes and collaborate with leadership to implement corrective measures.
• Track appeal progress and outcomes through internal systems, updating records and performing necessary system maintenance.

Compliance & Clinical Support

• Maintain current knowledge of regulations impacting utilization review and reimbursement (e.g., TJC, AHA, PRO).
• Collaborate with physicians, case managers, and clinical departments to evaluate utilization and ensure appropriate documentation.
• Communicate potential compensable events or risk-related findings to department leadership.
• Participate in initiatives to strengthen the revenue cycle process and prevent technical or process-related denials.

Administrative Duties & Organizational Support

• Complete mandatory training, competencies, and compliance requirements within established deadlines.
• Actively participate in department meetings and quality improvement efforts.
• Support departmental special projects and process improvement initiatives as assigned.

Organizational Commitments

Beacon Health System Mission:

We deliver outstanding care, inspire health, and connect with heart.

Core Values:

• Trust
• Respect
• Integrity
• Compassion

Service Goals:

• Personally connect
• Keep everyone informed
• Be on their team

The Beacon Way – Operating System:

• Leverage innovation everywhere
• Cultivate human talent
• Embrace performance improvement
• Build greatness through accountability
• Use information to improve and advance
• Communicate clearly and continuously

Qualifications

Education & Licensure:

• Graduate of an accredited Nursing program.
• Current and valid Registered Nurse (RN) license in the State of Indiana.

Experience:

• Minimum of two (2) years clinical nursing experience required.
• At least two (2) years of experience in utilization review or appeals management preferred.

Knowledge & Skills

• Comprehensive understanding of the healthcare revenue cycle, including utilization review, patient access, charge capture, and medical billing.
• Strong analytical and critical thinking abilities for reviewing medical records and identifying care documentation discrepancies.
• Working knowledge of reimbursement policies, managed care principles, and post-acute care processes.
• Excellent verbal and written communication skills, including the ability to draft persuasive appeal letters and provide education to clinical and administrative staff.
• Strong interpersonal skills to collaborate with medical providers, insurance representatives, and patient families.
• Self-motivated, detail-oriented, and capable of making independent decisions under pressure.
• Proficient in hospital systems (e.g., Star McKesson, Cerner PowerChart, PIC, Cobius) and standard office software (Word, Excel, Internet).

Working Conditions

• Primarily office-based with rounds in clinical areas for record reviews.
• Travel between Beacon Health System facilities may be required.
• May encounter biohazard exposure and emotionally distressed patients or families.

Physical Requirements

• Must possess the physical stamina and capability to perform all essential functions of the role effectively.