Denials, Grievances and Appeals RN - Utilization Management - Southwestern Health Resources (SWHR)

Here’s What You Need

Education

• Associate’s or Bachelor’s degree in Nursing required.
• Master’s degree in Nursing preferred.

Experience

• Require 2 years of Denials, Grievances and Appeals experience in a Managed Care/Utilization Management setting.
• Require 2 years of direct clinical or patient care experience as an RN, in an acute care setting, preferably in ER, ICU, or Medical/Surgical unit.
• Prefer Medicare Advantage experience.

Licenses & Certifications

• Current and active State of Texas or Compact Registered Nurse (RN) License upon hire required. 
• Certified Case Manager (CCM) Certification upon hire preferred. 

Skills & Abilities

• Working knowledge of computers and basic software application used in job functions such as word processing, graphics, databases, spreadsheets, etc.
• Strong analytical and organizational skills.
• Working knowledge and ability to apply professional standards of practice in work environment.
• Knowledge of specific regulatory, Texas Department of Insurance statutes, NCQA, URAC, CMS, and managed care requirement.
• Develop and sustain effective and professional working relationships with peers, leaders, and internal teams.

What You Will Do

Position Responsibilities

The Denials, Grievances & Appeals RN will use their clinical knowledge, experience, and advanced critical thinking to ensure accuracy and integrity of the full life cycle of medical necessity denial determinations is properly administered. This includes ensuring language utilized in denial determination letters is clear, compliant, clinically sound, professional, accurate, and aligns with clinical requirements relative to regulatory, state, and federal documentation requirements. This position is expected to fully understand the nuances of medical necessity criteria and utilization management in a managed care setting. This position will partner with Corporate Compliance for any regulatory questions or concerns as they arise. The Denials, Grievances & Appeals RN will also be responsible for ensuring that all the work completed by the LVN/LPN staff meet all clinical documentation integrity and regulatory standards for Utilization Management. The RN will act as a clinical resource and point of contact for LVNs/LPN's through applying and demonstrating advanced nursing knowledge as it pertains to clinical judgment, complex clinical verbiage, and clinical denial rationales requiring collaboration with Medical Directors or clinical leadership. The RN will use their advanced knowledge to identify areas for improvement in Denials, Grievance & Appeals department, and partner with clinical leadership to effectuate process improvement and positive change.

Position Functions

• Ensure denial/appeal letters are reviewed, edited, and sent to Compliance for approval within set state regulatory time frames.
• Evaluate letter correspondence for content, clarity, accuracy, and consistency.
• Collaborate with Corporate Compliance in addition to leaders, clinical and non-clinical staff, as well as administrative and clerical personnel.
• Work as a team to complete departmental tasks to meet deadlines and accomplish department objectives.
• Complete a thorough review of all letters while adhering to regulatory standards, and internal SWHR resources including payer delegation agreements.
• Meet with your Supervisor, Manager or Director to discuss any questions or issues regarding your workload, request guidance, and/or disseminate feedback or concerns stemming from letter correspondence.
• Assist Leadership with projects and initiatives, as needed.
• Participate in the review of audit findings as needed.
• Package & send appeal and grievance information to the HP, monitors for the outcome of appeal and takes action accordingly (notify the provider and member as per delegation agreement), track all appeal information.
• Provide after-hours coverage for appeals and documents accordingly.
• The RN will provide direction, guidance, and give feedback to LVNs/LPNs, and non-clinical associates regarding clinical workflows as they pertain to areas involving clinical verbiage, clinical rationale, clinical judgment, and clinical knowledge of requested services which have not been approved by the Medical Director.
• The RN will demonstrate and apply RN level nursing knowledge in working with LVN's/LPNs or non-clinical associates when communicating with Medical Directors regarding clinical determinations and make recommendations for revisions (if needed).
• The RN will act as a clinical advocate to LVN’s/LPN’s and non-clinical associates by delivering feedback and identifying areas of opportunity for improvement with clinical correspondence process and procedures.

Why Southwestern Health Resources 

As a Southwestern Health Resources employee, you’ll enjoy, comprehensive benefits, including a 401(k) with match; paid time off; competitive health insurance choices; healthcare and dependent care spending account options; wellness programs to keep you and your family healthy; tuition reimbursement; a student loan repayment program; and more.

• Additional perks of being an SWHR employee:
• Gain a sense of accomplishment by contributing to a teamwork environment.
• Positively impact patients’ quality of life.
• Receive excellent mentorship, comprehensive training and dedicated clinical and administrative leadership resources.
• Enjoy opportunities for growth.

Explore Southwestern Health Resources Careers for more information and to search all career opportunities.

Our Recruitment team invites you to contact us with any questions at recruitment@texashealth.org

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