Boston Medical Center (BMC) · 1 day ago
Denials and Appeals Administrator
United States
Full-time
Remote
Senior Level
$39.90/hr - $57.93/hr
5+ years expBoston Medical Center (BMC) is seeking a Denials and Appeals Administrator to oversee the pre-denial and appeal processes as part of their Utilization Review efforts. The role involves validating patient placements, securing authorizations for clinical services, and ensuring compliance with CMS guidelines.
Health CareHospitalMedicalNon Profit
Responsibilities
Responsible for the Pre-denial/ Denial and appeal process in addition to Utilization Review
Validate the patient’s placement to be at the most appropriate level of care based on nationally accepted admission criteria
Use medical necessity screening tools, such as InterQual or MCG criteria, to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient’s expected length of stay
Secure authorization for the patient’s clinical services through timely collaboration and communication with payers as required
Follow the UR process, in addition to the pre-denial and denial/appeal process as defined in the attached job description and in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review
Qualification
Required
Nursing degree: Diploma, ASN or BSN (preferred), Ability to obtain BSN within 4 years
Minimum 5 years or more related experience preferably in a healthcare case management and patient insurance/billing environment
Work requires a comprehensive knowledge of clinical documentation and medical coding, and a working knowledge of patient financial billing regulations/requirements, reimbursement, managed care in order to understand the clinical and billing systems; review, interpret, and analyze clinical and patient financial reports and data; and plan, coordinate and prepare for corrections to accounts
Work requires a comprehensive understanding of medical records coding, patient billing policies and procedures and health insurance standards, as well as knowledge of supervisory/managerial techniques and principles in order to control hospital financial billing activities
Work requires advanced interpersonal skills necessary to work with physicians, hospital directors and managers to affect changes in clinical and fiscal operations, policies and procedures; to provide guidance, communicate and interpret complex patient billing and compliance information
Preferred
3-4 years supervisory experience preferred
Medical records coding experience is desirable
Benefits
Medical, dental, vision, pharmacy
Discretionary annual bonuses
Merit increases
Flexible Spending Accounts
403(b) savings matches
Paid time off
Career advancement opportunities
Resources to support employee and family well-being
Company
Boston Medical Center (BMC)
Boston Medical Center (BMC) is a 511-bed, equity-led academic medical center and a proud member of the Boston Medical Center Health System.
5001-10000 employees
H1B Sponsorship
Boston Medical Center (BMC) has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (53)
2024 (51)
2023 (51)
2022 (38)
2021 (26)
2020 (32)
Funding
Current Stage
Late StageTotal Funding
$342.49MKey Investors
AmeriCorps Public AlliesNational Institute on Drug Abuse (NIDA)The Boston Foundation
2024-07-09Grant· $0.06M
2023-02-23Debt Financing· $232M
2019-04-23Grant· $89M
Leadership Team
David Beck
Senior Vice President & Chief Legal Counsel
Recent News
2025-11-11
2025-11-10
Company data provided by crunchbase