JOB SUMMARY: The Appeals Nurse assists in the review of medical records submitted for appeals by providers due to adverse determination. Utilize evidence based criteria, regulatory guidelines and Medical Affairs departmental policies for medical necessity and level of care determination. Provides written response of the outcome of the appeals finding to the appealing provider and member. Assists in the ongoing development and maintenance of a database for tracking, trending and reporting appeals cases.
1. Education/Specialized Training/Licensure: Registered Nurse, current Texas License 2. Work Experience : One (1) year of experience utilizing evidence based criteria in medical reviews; One (1) year in acute care setting or managed care setting preferred 3. Management Experience : N/A 4. Software Operated: Microsoft Office (Word, Excel, Access and Outlook)
SPECIAL REQUIREMENTS: 1. Communication Skills: Above Average Verbal (Heavy Public Contact) Exceptional Verbal (e.g., Public Speaking) Writing /Composing: Correspondence / Reports
2. Other Skills: Analytical, Medical Terminology, MS Word, MS Excel, MS Access
3. Advanced Education: Advanced Training Specialty: RN, Current TX License
4. Work Schedule: Flexible
5. Other Requirements: Strong written and verbal communications skills.
The Harris Health System is a fully integrated healthcare system that cares for all residents of Harris County, Texas. We are the first accredited healthcare institution in Harris County to be designated by the National Committee for Quality Assurance as a Patient-Centered Medical Home, and are one of the largest systems in the country to achieve the quality standard. Our system includes 23 community health centers, five school-based clinics, a dental center and dialysis center, mobile health units, a rehabilitation and specialty hospital and two full-service hospitals.Ben Taub Hospital is a world renowned Level I Trauma Center with 586 licensed acute-care beds and provides a wide range of specialty care outpatient services. Lyndon B. Johnson Hospital is a 328 licensed bed acute-care hospital with a newly expanded Level III trauma center and a distinguished regional center for neonatal intensive care for high-risk deliveries.Harris Health is a teaching system for Baylor College of Medicine and The University of Texas Health Science Center at Houston (UTHealth). We train the next generation of healthcare providers on the latest medical procedures and technological breakthroughs.With... our fully integrated electronic medical records system, we offer patients the convenience and assurance that their medical history is accurate, safe and available when and where it is needed. Our Medical Home designation ensures that we offer a full range of preventive, specialty and acute care services for the entire family.