STAR+PLUS Appeals Nurse RN

Job Summary

Appeals Nurse assists in the review of medical records submitted for appeals by providers due to adverse determination. Utilizes evidence-based criteria, regulatory guidelines, and Medical Affairs departmental policies for medical necessity and level of care determination. Provides written responses of the outcome of the appeals findings to the appealing provider and member. Assists in the ongoing development and maintenance of a database for tracking, trending, and reporting appeals cases.

Job Specifications and Core Competencies

• Reviews and provides resolution of appeals, per regulatory guidelines to providers for cases submitted for appeals review due to adverse determination.
• Accurately evaluates all cases by utilizing evidence-based criteria and Medical Affairs departmental policies for medical necessity and level of care.
• Notifies the Claims department the same day of overturned adverse determination requiring adjustments.
• Logs and closes out all cases in the appeal database after resolution the same day.
• Provides written feedback to senior leadership to improve inter-rater reliability.
• Assists in the ongoing development and maintenance of the database for tracking, trending, and reporting all data as related to adverse determination received by CHC, by providing feedback to senior leadership.
• Actively contributes to achievement of departmental goals, as identified in Department's annual business plan, including specific departmental process improvement plans, and other duties as assigned.
• Reports to Position Title: Sr. Manager Complaints & Appeals

Qualifications

• Registered Nurse, current Texas License required.
• One (1) year of experience utilizing evidence-based criteria in medical reviews required.
• One (1) year of experience in acute care setting and managed care setting required.
• Utilization prior auth experience, claim appeals, and/or medical appeals experience required.
• Management experience (Years and Area): N/A

Software Proficiencies

• Microsoft Office (Word, Excel, Access and Outlook)

Other

• Strong written and verbal communications skills.