Appeals and Denials RN Manager

Mount Sinai Medical Center Miami Beach, FL, US

Appeals and Denials Nurse Manager

(Onsite - Miami Beach)

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.

Position Responsibilities:

Management of Payor Processes and Relationships

Develops and maintains effective relationships with payors, including contact as required with representatives from payors to ensure accomplishment of utilization management activities
Oversees the management of observation cases, both concurrently and retrospectively, as needed.
Supports the clinical denial management process, ensuring that all denials related to medical necessity and delays in service/discharge are identified and addressed promptly and documented appropriately
Ensures concurrent flow of information between the Care Management Department and other MSMC departments responsible for managed care contracts and patient accounts/billing
Participates with other MSMC entities who are involved in the denial management process to ensure that denials and appeals are tracked, trended, and reported to the Director regularly
Is familiar with Payor policies and appeals processes and ensure appeals are completed and followed up on in a timely manner

Department Data and PI

Generates and interprets reports/conducts audits to ensure compliance with documentation and to identify opportunities for improvement; follows up on any areas/individuals identified as having room for improvement
Collaborates with other departments to generate outcome data as needed to measure and trend performance indicators identified in the Utilization/Medical Management Plan.
Ensures the management of data collection, aggregation, and dissemination across the continuum, including: clinical, financial, and operational performance; this includes concurrent and retrospective medical record review

Staff Development

Participates in hiring, reviews, discipline, and grievance handling to ensure optimal individual and team performance.
Participates in staff development activities, interacting as needed with the director, customers, and others to continuously improve competency and effectiveness of the department.
Identifies and addresses skills or behaviors requiring improvement, both at an individual level and at a department level.
Provides coaching as needed to optimize performance and ensure safe and satisfactory care to patients and optimal customer service.

Other Departmental Functions

Supports Director in development of department operational budget. Analyzes costs, identifies/develops strategies to ensure compliance with budgetary constraints and provides justifications for budget variances.
Provides daily oversight and management to payor teams; Ensures that all of the functions of the staff are accomplished

Managerial Behavior and Development

Engages in self-development in clinical, professional, and managerial areas; successfully completes leadership development curriculum.
Adheres to standards, policies and procedures at both the hospital and Departmental level.
Promotes a service orientation in the performance of position duties and responsibilities and in interactions with patients, hospital staff and visitors.

Qualifications:

Bachelor's Degree
5 years management or related experience

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. Our robust employee benefits package includes:

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 selected positions and more!

Share this job

Related Jobs

Assistant Nurse Manager - Intermediate Care Unit (IMCU)

Cleveland Clinic Weston, FL

At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day. We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One. Job Title Assistant Nurse Manager - Intermediate Care Unit (IMCU) Location Weston Facility Florida Weston Hospital Department Weston 5 Tower-Weston Hospital Job Code 000880 Shift Nights Schedule 7:00pm-7:30am Job Summary Job Details Join Cleveland Clinic Weston Hospital’s team of caregivers that remain on the leading edge of technology and education, all while consistently providing patient-centered healthcare. As part of Cleveland Clinic’s Florida region, Weston Hospital is recognized as one of the top hospitals in the Miami-Fort Lauderdale and Florida regions. Here, you will receive endless support and appreciation while building a rewarding career with one of the most respected healthcare organizations in the world. Weston Hospital’s Intermediate Care Unit (IMCU) provides specialized care for patients with gastrointestinal disorders as well as those recovering from heart, liver, and kidney transplants, offering an advanced level of monitoring and treatment that exceeds routine care while remaining distinct from the intensity of critical care. As Assistant Nurse Manager (ANM), you will provide clinical supervision and unit coordination within the IMCU. With an emphasis on professional development and success, you will encourage caregivers to enhance their skills and patient experience through improvement initiatives and incentives. This position offers a great way to gain extensive leadership experience while continuing to provide the best support and treatment possible. A caregiver in this role works nights from 7:00 p.m. – 7:30 a.m. with rotating weekend requirements. A caregiver who excels in this role will: Supervise and coordinate unit clinical operations. Provide patient care. Facilitate communication and collaboration among unit caregivers and other departments/units. Review major operational patient care issues with Nurse Managers. Provide ongoing clinical evaluations of caregivers, counsel caregivers on performance issues, administer initial corrective actions and monitor attendance issues. Interview, select and orient new caregivers. Prepare work schedules to ensure adequate coverage on all shifts. Participate in and support quality improvement projects, outcomes, studies and research initiatives. Assume responsibilities of the Nurse Manager in their absence. Minimum qualifications for the ideal future caregiver include: Graduate from an accredited school of Professional Nursing Bachelor’s of Science in Nursing (BSN) Current state licensure as a Registered Nurse (RN) Basic Life Support (BLS) Certification through the American Heart Association (AHA) or American Red Cross Two years of recent clinical nursing experience Strong demonstrated clinical knowledge and skills Preferred qualifications for the ideal future caregiver include: Charge Nurse or Leadership experience Three to five years of nursing experience in an acute care setting Physical Requirements: Requires full range of motion, manual and finger dexterity and eye-hand coordination. Requires standing and walking for extensive periods of time. Requires corrected hearing and vision to normal range. Requires some exposure to communicable disease or bodily fluids. Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. Physical Demand requirements are in excess of those for Light Work. Personal Protective Equipment: Follows standard precautions using personal protective equipment as required. The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances. Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility. Please review the Equal Employment Opportunity poster . Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities

Assistant Nurse Manager Ambulatory – Transplant Center

Cleveland Clinic Weston, FL

At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day. We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One. Job Title Assistant Nurse Manager Ambulatory – Transplant Center Location Weston Facility Florida Weston Hospital Department Transplant Center-Weston Hospital Job Code 000311 Shift Days Schedule 7:00am-4:30pm Job Summary Job Details Join Cleveland Clinic Weston Hospital’s team of caregivers that remain on the leading edge of technology and education, all while consistently providing patient-centered healthcare. As part of Cleveland Clinic’s Florida region, Weston Hospital is recognized as one of the top hospitals in the Miami-Fort Lauderdale and Florida regions. Here, you will receive endless support and appreciation while building a rewarding career with one of the most respected healthcare organizations in the world. As an Assistant Nurse Manager, you will manage and monitor the daily clinical operations of the Transplant Center. In this role, you will provide professional nursing care to a specific patient population across a variety of settings and oversee RNs, LPNs, MAs, and other patient care providers within the service line to ensure high-quality care. You will anticipate and resolve patient care and personnel issues, participate in hiring and onboarding of staff, conduct annual performance reviews, and support ongoing performance improvement initiatives. This position offers a valuable opportunity to gain extensive leadership experience while delivering high-quality support and care within a focused clinical environment. It provides broad skills and educational development, serving as a strong steppingstone into higher-level leadership roles. A caregiver in this role works days from 7:00 a.m. – 4:30 p.m. A caregiver who excels in this role will: Monitor daily clinical operations of outpatient clinics. Provide professional nursing care to a specific patient population in a variety of settings. Oversee RNs, LPNs, MAs and other patient care providers of a specified service line to ensure quality of care. Anticipate and resolve patient care and personnel issues. Participate in hiring and onboarding of personnel, annual performance reviews, and performance improvement. Coordinate activities to ensure quality and safe patient care. In conjunction with the clinical manager, ensure maintenance of annual staff competencies and continuing education. Perform duties of the RN Ambulatory as needed. Collaborate with care coordinators to ensure a smooth and effective transition of care. Participate and/or coordinate committees, task forces, and continuous improvement activities. Participate in department leadership meetings. Ensure compliance with regulatory standards and patient safety initiatives. Assume responsibilities of the clinical manager as needed. Attend Organ Transplant conferences. Minimum qualifications for the ideal future caregiver include: Graduate from an accredited school of professional nursing (ADN or BSN program) Bachelor’s Degree in Nursing (BSN) Current state licensure as a Registered Nurse (RN) Basic Life Support (BLS) certification through the American Heart Association (AHA) or American Red Cross Two years of recent RN experience Strong leadership, communication, problem-solving, decision-making and conflict resolution skills Preferred qualifications for the ideal future caregiver include: Previous supervisory experience Transplant experience Knowledge of Oracle, Excel and Outlook Physical Requirements: Requires full range of motion, manual and finger dexterity and eye-hand coordination. Requires corrected hearing and vision to normal range. May requires some exposure to communicable diseases or bodily fluids. Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. Physical Demand requirements are in excess of those for Light Work. Personal Protective Equipment: Follows Standard Precautions using personal protective equipment as required for procedures. The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances. Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility. Please review the Equal Employment Opportunity poster . Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities

Assistant Nurse Manager - Intermediate Intensive Care Unit (IMCU)

Cleveland Clinic Weston, FL

At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day. We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One. Job Title Assistant Nurse Manager - Intermediate Intensive Care Unit (IMCU) Location Weston Facility Florida Weston Hospital Department Intermediate ICU-Weston Hospital Job Code 000880 Shift Nights Schedule 7:00pm-7:30am Job Summary Job Details Join Cleveland Clinic Weston Hospital’s team of caregivers that remain on the leading edge of technology and education, all while consistently providing patient-centered healthcare. As part of Cleveland Clinic’s Florida region, Weston Hospital is recognized as one of the top hospitals in the Miami-Fort Lauderdale and Florida regions. Here, you will receive endless support and appreciation while building a rewarding career with one of the most respected healthcare organizations in the world. Weston Hospital’s Intermediate Intensive Care Unit (IMCU) provides care to patients who require a higher level of care than routine, yet not to the intensity of critical care. As Assistant Nurse Manager (ANM), you will provide clinical supervision and unit coordination within the IMCU. With an emphasis on professional development and success, you will encourage caregivers to enhance their skills and patient experience through improvement initiatives and incentives. This position offers a great way to gain extensive leadership experience while continuing to provide the best support and treatment possible. A caregiver in this role works nights from 7:00 p.m. – 7:30 a.m. with alternating weekend requirements. A caregiver who excels in this role will: Supervise and coordinate unit clinical operations. Provide patient care. Facilitate communication and collaboration among unit caregivers and other departments/units. Ensure continuity of patient care information between shifts. Coordinate patient admitting, discharges, transfers and other operational issues. Review major operational patient care issues with Nurse Managers. Provide ongoing clinical evaluations of caregivers, counsel caregivers on performance issues, administer initial corrective actions and monitor attendance issues. Interview, select and orient new caregivers. Prepare work schedules to ensure adequate coverage on all shifts. Participate in and support quality improvement projects, outcomes, studies and research initiatives. Assume responsibilities of the Nurse Manager in their absence. Minimum qualifications for the ideal future caregiver include: Graduate from an accredited school of professional nursing Bachelor’s of Science in Nursing (BSN) Current state licensure as a Registered Nurse (RN) Basic Life Support (BLS) Certification through the American Heart Association (AHA) or American Red Cross Two years of recent clinical nursing experience Strong demonstrated clinical knowledge and skills Preferred qualifications for the ideal future caregiver include: Prior experience as a charge nurse Leadership experience Our caregivers continue to create the best outcomes for our patients across each of our facilities. Click the link and see how we’re dedicated to providing what matters most to you: https://jobs.clevelandclinic.org/benefits-2/ Physical Requirements: Requires full range of motion, manual and finger dexterity and eye-hand coordination. Requires standing and walking for extensive periods of time. Requires corrected hearing and vision to normal range. Requires some exposure to communicable disease or bodily fluids. Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. Physical Demand requirements are in excess of those for Light Work. Personal Protective Equipment: Follows standard precautions using personal protective equipment as required. The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances. Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility. Please review the Equal Employment Opportunity poster . Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities

ICU

Full-time

1 week ago

RN - Intermediate Intensive Care Unit (IMCU)

Cleveland Clinic Weston, FL

At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day. We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One. Job Title RN - Intermediate Intensive Care Unit (IMCU) Location Weston Facility Florida Weston Hospital Department Intermediate ICU-Weston Hospital Job Code 000648 Shift Nights Schedule 7:00pm-7:30am Job Summary Job Details Join Cleveland Clinic Weston Hospital’s team of caregivers that remain on the leading edge of technology and education, all while consistently providing patient-centered healthcare. As part of Cleveland Clinic’s Florida region, Weston Hospital is recognized as one of the top hospitals in the Miami-Fort Lauderdale and Florida regions. Here, you will receive endless support and appreciation while building a rewarding career with one of the most respected healthcare organizations in the world. Weston Hospital’s Intermediate Intensive Care Unit (IMCU) provides care to patients who require a higher level of care than routine, yet not to the intensity of critical care. As an RN on this team, you will help ensure patients receive the attention, resources and education they need during and after treatment. You will deliver exceptional care, interacting directly with patients and their families to enhance their overall experience and provide education as needed. How You’ll Benefit Take advantage of industry leading benefits, including our RN Loan Repayment program, which helps pay off student debt, and our Tuition Reimbursement program to reinvest in your career. And if you’re relocating to join us, you could be eligible for relocation assistance. Our Center for Workplace Violence Prevention and Caregiver Well-Being sets caregiver safety as a priority, identifying, reporting and responding to incidents and providing safety resources. A caregiver in this role works nights from 7:00 p.m. – 7:30 a.m. with rotating weekend requirements. A caregiver who excels in this role will: Provide direct nursing care. Implement, monitor, evaluate, update and revise patient care plans. Monitor, record, document and communicate patients’ conditions. Administer prescribed medications and treatments. Note and carry out physician and nursing orders. Assess and coordinate patients’ discharge needs. Educate patients and their families. Minimum qualifications for the ideal future caregiver include: Graduate from an accredited school of professional nursing (Diploma, ADN or BSN program) Current state licensure as a Registered Nurse (RN) Basic Life Support (BLS) Certification through the American Heart Association (AHA) or American Red Cross One year of current acute care RN experience OR licensed military RN experience Preferred qualifications for the ideal future caregiver include: Bachelor’s of Science in Nursing (BSN) Physical Requirements: Requires full range of body motion including handling and lifting patient, manual and finger dexterity, and eye-hand coordination. Requires standing and walking for extended periods of time. Requires corrected vision and hearing to normal range. Requires working under stressful conditions and irregular hours. Exposure to communicable diseases and/or body fluids. Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. Physical Demand requirements are in excess of those for Light Work. Personal Protective Equipment: Follows standard precautions using personal protective equipment as required. The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances. Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility. If applying for a Florida position, please see the following website for more information on the background screening requirements required by the Agency of Health Care Administration: https://info.flclearinghouse.com/ Please review the Equal Employment Opportunity poster . Cleveland Clinic is pleased to be an equal employment opportunity employer.

ICU

Full-time

1 week ago

RN - Surgical Intensive Care Unit/Cardiovascular Intensive Care Unit

Cleveland Clinic Weston, FL

At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day. We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One. Job Title RN - Surgical Intensive Care Unit/Cardiovascular Intensive Care Unit Location Weston Facility Florida Weston Hospital Department Job Code 000648 Shift Nights Schedule 7:00pm-7:30am Job Summary Job Details Join Cleveland Clinic Weston Hospital’s team of caregivers that remain on the leading edge of technology and education, all while consistently providing patient-centered healthcare. As part of Cleveland Clinic’s Florida region, Weston Hospital is recognized as one of the top hospitals in the Miami-Fort Lauderdale and Florida regions. Here, you will receive endless support and appreciation while building a rewarding career with one of the most respected healthcare organizations in the world . The Surgical Intensive Care Unit (SICU)/Cardiovascular Intensive Care Unit (CVICU) offers unmatched medical services to populations recovering from heart transplants, cardiothoracic surgeries, open heart surgeries and other procedures. As an RN on this team , you will assist between one and three patients at a time, allowing you to truly develop meaningful relationships with each person and enhance their healthcare experience. This opportunity is a steppingstone to a myriad of advanced positions and responsibilities within the hospital organization, as the hands-on skills and knowledge gained is valuable in any healthcare setting. Whether you are an experienced RN or looking for an exciting new venture, c ome find your place and make a meaningful difference in the lives of both patients and fellow caregivers. A caregiver in this position works nights from 7:00 PM – 7:30 AM . A caregiver who excels in this role will: Provide direct nursing care. Implement, monitor, evaluate, update and revise patient care plans. Monitor, record, document and communicate patients’ conditions. Administer prescribed medications and treatments. Note and carry out physician and nursing orders. Assess and coordinate patients’ discharge needs. Educate patients and their families . Minimum qualifications for the ideal future caregiver include: Graduate from an accredited school of P rofessional N ursing Current state licensure as a Registered Nurse (RN) One year of current acute care RN experience OR licensed military RN experience Basic Life Support (BLS) C ertification through the American Heart Association (AHA) Advanced Cardiac Life Support (ACLS) C ertification through the American Heart Association (AHA) upon or within one year of hire Preferred qualifications for the ideal future caregiver include: Bachelor ’s of S cience in N ursing (BSN) Cardiac Stepdown experience Our caregivers continue to create the best outcomes for our patients across Physical Requirements: Requires full range of body motion including handling and lifting patient, manual and finger dexterity, and eye-hand coordination. Requires standing and walking for extended periods of time. Requires corrected vision and hearing to normal range. Requires working under stressful conditions and irregular hours. Exposure to communicable diseases and/or body fluids. Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. Physical Demand requirements are in excess of those for Light Work. Personal Protective Equipment: Follows standard precautions using personal protective equipment as required. The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances. Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility. If applying for a Florida position, please see the following website for more information on the background screening requirements required by the Agency of Health Care Administration: https://info.flclearinghouse.com/ Please review the Equal Employment Opportunity poster . Cleveland Clinic is pleased to be an equal employment opportunity employer.