Appeals Nurse RN - Community Health Choice
Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
• Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
• Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
• Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
Skills / Requirements
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)
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.
RESPONSIBLE TO: Supervisor/Manager