STAR+PLUS Appeals Nurse RN

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.

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.