Clinical Reviews, Denial and Appeals RN Full time

Heres What You Need

• Associates Degree in Nursing required

• Bachelors Degree in Nursing preferred

• 3 years Inpatient clinical nursing experience in an acute hospital setting required and

• 1 year UM experience including knowledge and application of Milliman or InterQual criteria required

• Case management experience preferred

• Denials and Appeals experience preferred

• RN license to practice in the state of Texas upon hire required

What You Will Do

• Communicates and collaborates as needed with physicians Care Management staff Business Office Nursing and ancillary departments to proactively address patient care issues and denials management

• Conducts the necessary research for appealing denied days/stays through electronic record review. Requires access to Care Connect patient records for all THR hospitals.

• Collaborates with physicians when needed to develop comprehensive and effective appeal strategies for medical necessity denials.

• Reviews clinical documentation in order to determine if medical necessity criteria were met.

• Prepares appeal letters and notifications to appropriate parties and hospital departments within the specified time frames and files appeal per contracted agreement.

• Tracks monitors manage clinical denials and appeals and appeal outcomes for reporting as requested.

• Reports denial trends to the respective departments are used for educational corrective action.

• Develops and maintains relationships with other departments related to appeals and denial management.

• Serves as an educator and resource to the Care Management Staff Physicians and other hospital disciplines as required/designated regarding Medicare Medicaid and Commercial payer guidelines.

• Reviews Medicare one day stays and conducts medical necessity internal audits (100% one day stays)

Additional perks of being a Texas Health employee

• Benefits include 401k PTO medical dental Paid Parental Leave flex spending tuition reimbursement Student Loan Repayment Program as well as several other benefits.

• Delivery of high quality of patient care through nursing education nursing research and innovations in nursing practice.

• Strong Unit Based Council (UBC).

• A supportive team environment with outstanding opportunities for growth

Entity Highlights:

At Texas Health Resources our mission is to improve the health of the people in the communities we serve.

Our award-winning culture is a tribute to our amazing employees. Were thrilled to be a 2023 FORTUNE Magazines 100 Best Companies to Work For for the 9th year in a row! We strive to create an atmosphere of respect integrity compassion and excellence for all. Were committed to diversity in our workforce and our mission to serve spreads across ethnic cultural economic and generational boundaries. Join us and to do your lifes best work here!

Explore our Texas Health careers site for info like Benefits Job Listings by Category recent Awards weve won and more.

Do you still have questions or concerns Feel free to email your questions to

#LI-LD1

Clinical Reviews Denial and Appeals RN

Bring your passion to THR so we are Better Together

Work location: Remote (Local candidates only)

Work hours: Monday Friday from 8:00am 4:30pm

Clinical Review and Denials Department highlights:

• Flexible schedule

• Remote work environment

• Collaborative team approach

• Work/life balance

• Opportunities for advancement

• Opportunities for tuition reimbursement for approved degrees