JOB SUMMARY
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

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. Ensures that all resolution letters are put out for mailing within 2 business days of determination being rendered.
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 data base after resolution
the same day.
Providing 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:
Education/Specialized Training/Licensure: Registered Nurse, current Texas License required.

Work Experience (Years and Area): 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.