Denial and Appeal Coordinator en TCH Medical Center
TCH Medical Center · Bellaire, Estados Unidos De América · Onsite
- Professional
- Oficina en Bellaire
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?
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
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.
