Denial and Appeal Coordinator

 
Position: Denial and Appeal Coordinator

Job ID: 160625

Location: US-TX-Houston

Department: UM DENIAL AND APPEAL

Talent Area: Registered Nurse

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p

About Texas Children's Hospital

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.   To join our community of 14,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.   Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

Summary:

We are searching for a Denial and Appeal Coordinator ­– someone who works well in a fast-paced setting. In this position, you will work with medical directors/physician reviewers, network physicians and network facilities to ensure consistent clinical evaluation and processing of cases not meeting medical necessity criteria or those being appealed for reasons of medical necessity decisions.

 

Think you’ve got what it takes?



Responsibilities :

 Job Duties & Responsibilities

  • Teams with physician team to identify strategy for action and to be used as well as choice of guideline citation/response based on category of denial or appeal.
  • Ensures for the provision of continuity of care needs as required and serves as advocate on behalf of members and families for out of network authorization approvals.
  • Communicates with internal staff, physicians, hospital representatives and other providers on status of case review and due process and explanation of rationale, process and regulatory processing.
  • Collaborates with nurse reviewers, medical directors, external physician reviewers, and network providers.
  • Established integrity of the review process of denial and appeal compliance and policies and procedures, managed care and Medicaid through informing and auditing practice.


Qualifications:

Being fully vaccinated against COVID-19 is required for all employees at Texas Children’s, unless approved for a medical or religious exemption

 

Skills & Requirements

  • Diploma in Nursing or associate degree in nursing or associate degree in a related field required
  • Bachelor’s degree in Nursing preferred
  • RN - Lic-Registered Nurses Texas Board of Nursing required
  • 4 years’ of nursing experience required

**Prior experience with medical necessity reviews highly preferred**



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