Clinical Appeals Nurse - PCHP

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that's served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It's our passion.

Primary Purpose

Responsible for performing clinical reviews of previously denied cases in which a formal appeal request has been made. Accountable for ensuring appeal reviews are completed in a timely manner in accordance with standards, guidelines, and contractual requirements.

Minimum Specifications

Education: Graduate from an accredited school of nursing required. Bachelor's degree in nursing preferred.

Experience: 3+ years of acute clinical nursing or medical management experience required. Prior clinical appeals experience preferred. Experience in Texas Medicaid, Medicaid, or a Medicaid managed care organization preferred.

Certification/Registration/Licensure

- Current and unrestricted licensure as a RN in the State of Texas required.

Skills or Special Abilities

- Knowledge of utilization management and case management principles.

- Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines.

- Ability to communicate complex information in understandable terms.

- Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships across and beyond the organization.

- Excellent analytical and problem-solving skills.

- Strong time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities.

- Ability to write clearly and succinctly with a high level of attention to detail. - Proficient computer and Microsoft Office skills. Ability to learn new software programs.

- Knowledge of Texas Medicaid, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual.

- Familiar with InterQual and Texas Medicaid provider procedures manual and utilization guidelines.

- Solid understanding of managed care and medical terminology.

Responsibilities

- Clinical Appeals Identifies and requests relevant information needed to investigate an appeal. Prepare appeal reviews based on clinical guidelines and department policies.

- Provides case summary along with recommendations to the medical director for final determination.

- Ensures all reviews are completed within established timelines and in accordance with regulatory and contractual requirements.

- Monitor cases involving medical, quality of care, or service decisions. Oversee and participate in fair hearing cases with the State. Assists with preparing audit reports.

- Documentation Maintains record integrity by accurately entering the case actions to the assigned cases.

- Documents and maintains clinical information in health management systems ensuring all pertinent information is entered in a timely manner and in accordance with department guidelines.

- Identifies clinical documentation issues and provides recommendations to management.

- Assists with notification process to members and providers on the clinical appeal decisions.

- Regulatory Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements.

- Professional Accountability Promotes and supports a culturally welcoming and inclusive work environment. Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values.

- Adheres to organizational policies, procedures, and guidelines.

- Completes assigned training, self-appraisal, and annual health requirements timely. Adheres to hybrid work schedule requirements.

- Attends required meetings and town halls. Recognizes and communicates ethical and legal concerns through the established channels of communication.

- Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information. Maintains confidentiality at all times.

- Performs other work as requested that is reasonably related to the employees position, qualifications, and competencies.

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.As part of our commitment to our patients and employees' wellness, Parkland Health is a tobacco and smoke-free campus.