Appeals & Grievances (Medical Auditor) RN

Baylor Scott & White Health - Temple, TX

Full-time - Mid Level

Hybrid - Temple, TX

Hospitals

About the position

The Appeals & Grievances (Medical Auditor) RN conducts reviews of medical records and plan documentation to conduct thorough written reviews of appeals, grievances, and reconsiderations using evidence-based medical guidelines to assist the Medical Director in determining the appropriateness of services. This is a hybrid position that requires the ability to work outside of standard business hours to meet regulatory timeframes.

Responsibilities

• Reviews clinical information for appeals and grievances (pre- and post-service denials) utilizing evidence-based medical criteria & plan policies.
• Extrapolates and concisely summarizes essential medical information for the Health Plan's Medical Directors and other reviewers.
• Uses knowledge of nursing process and pathophysiology to present a concrete, objective, and cohesive evaluation of members' dispute of adverse determinations.
• Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
• Ability to differentiate types of requests- appeals, grievances, and organization determinations, to ensure the correct processing of the issue.
• Identifies, escalates, and/or provides support for complex cases for referral to Case Management or Quality Improvement Department if a Quality of Care issue is identified.
• At times, may be called upon to educate members and providers on the appeal process.
• Documents accurately and comprehensively based on the standards of practice and current organization policies by drafting member and provider letter language for denials and approvals and appropriately annotating appeal records.
• Collaborates with leadership to provide orientation and ongoing education of new department employees.
• Participates in process improvement projects, including the evaluation, development and implementation of protocols, policies, and procedures to continuously enrich care coordination efforts and ensure evidence-based processes are utilized.

Requirements

• Current, active, unrestricted RN license to practice as a health professional within the scope of practice in the State of Texas.
• Minimum 2 years acute care clinical experience.
• Possess an Associate's degree in Nursing.
• Have at least 3 years of relevant work experience.

Nice-to-haves

• Bachelor of Science in Nursing or equivalent experience preferred.
• Experience in Utilization Management and/or Case Management preferred.

Benefits

• Eligibility on day 1 for all benefits
• Dollar-for-dollar 401(k) match, up to 5%
• Debt-free tuition assistance, offering access to many no-cost and low-cost degrees, certificates and more
• Immediate access to time off benefits