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We’re searching for an Appeal Coordinator, someone who’s ready to be part of the best ranked children’s hospital in Texas, and among the best in the nation. In this position, you will work with the Health Plan clinical review staff, medical directors/physician reviewers, network physicians and network facilities to ensure consistent clinical evaluation and processing of cases being appealed for reasons of medical necessity decisions. Documentation of these decisions and precise record keeping of notice to Members and network Providers is essential in complying with legal statue and accrediting standards supporting consumer rights.

Think you’ve got what it takes?

Job Duties & Responsibilities

• Performs necessary review to ensure compliance with HHSC and other regulatory entities.
• Collaborates: Teams with physician team to identify strategy for action and be used and choose guideline citation/response based on denial category.
• Develops: Training materials and examples for nursing staff to educate them in the use of criteria, benefit application, and the appeal, External Medical Review (EMR) and Fair Hearing process.
• Coordinates: Ensures continuity of care needs as required and serves as advocate on behalf of Members and families for out-of-network authorization approvals.
• Implements: Identifies problems/barriers/opportunities in the process and provides for resolution, revision of plans.
• Evaluates: Quarterly assesses status or appeal and activity program preparing a report for Texas to review and internal review.
• Analyzes requests against regulatory and decision-making guidelines and benefit allowance. Implements action in collaboration with physician reviewer panel and monitors decision making, timeliness, and processing of appeals, External Medical Review, and State Fair Hearing in accordance with regulatory and accrediting guidelines.
• Communicates with internal staff, Member/LAR, physicians, hospital representatives and other Providers on status of case review and due process and explanation of rationale, process, and regulatory processing.
• Collaborates with clinical reviewers, medical directors, external physician reviewers, and network Providers.
• Established integrity of the appeal review process and compliance with policies and procedures of the Health Plan, managed care and Medicaid through informing and auditing practice.
• Provide data for internal and external reporting.

Skills & Requirements

• Bachelors degree in nursing required (and is the preference) Or
  • Diploma in Nursing or associate degree in Nursing Or
  • an associate degree in a related field accepted by the Texas Board of Nursing for the purposes of obtaining and maintaining an RN license Or 
  • master's degree In Speech Language Pathology or 
  • master's degree in physical or 
  • occupational therapy
• Required Licenses/Certifications
  • RN - Lic-Registered Nurses by the Texas Board of Nursing or Nursing Licensure Compact Or
  • PT - Physical Therapist by the Texas Board Physical or Occupational Therapy Examiners  Or
  • OT - Occupational Therapist by the Texas Board Physical or Occupational Therapy Examiners Or
  • TX-SLP - Texas Speech Language Pathology by the Texas Department of Licensing and Regulation
• Required 3 years Nursing Experience or Speech Language Pathology Experience or OT/PT Experience or Utilization Management Experience