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HP Denials and Appeals Coord

Company: Cook Children's Healthcare
Location: Fort Worth
Posted on: February 17, 2020

Job Description:

Responsible for the overall management and communication of the denial and appeal process. This includes investigating and processing medical necessity appeal requests as well as acting as the. Subject matter expert for all adverse determination (medical necessity denial), and administrative/ technical denials as governed by the appropriate regulatory agency for a members benefit plan.

  • Registered Nurse; minimum of five (5) years clinical experience.
  • Bachelors degree in nursing.
  • 3 5 years utilization review/case management experience.
  • Minimum of 1 year experience in a Medicaid, Childrens Health Insurance Program, or STAR+PLUS managed care organization.
  • Experience with managed care denial and appeal processes preferred.
  • Knowledge of InterQual and/or Milliman clinical guidelines.
  • Excellent assessment, cognitive, and critical thinking skills.
  • Strong analytical skills including the ability to interpret and present information in a concise, meaningful way.
  • Must be able to make complex decisions, act in situations that are moderately to extremely difficult, work independently, and to meet tight deadlines.
  • Excellent vocabulary, grammar, spelling, punctuation, and composition skills proven through the development of written communication.
  • Demonstrated proficiency with Microsoft Office (Word, Excel, Outlook, and PowerPoint).
  • Typing speed 35 words per minute without errors.
  • Current unrestricted Registered Nurse licensure in Texas

Keywords: Cook Children's Healthcare, Fort Worth , HP Denials and Appeals Coord, Other , Fort Worth, Texas

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