POSITION SUMMARY AND RESPONSIBILITIES

Conducts comprehensive clinical reviews of adverse determinations related to medical necessity. Initiates outreach to providers to obtain clarification or additional documentation in alignment with established clinical criteria and organizational policies, to support Medical Director decision making.  Provides support for claim appeals in relation to medical necessity.  Ensures the timely and accurate resolution of appeal cases and supports organizational adherence to all state, federal, and accreditation standards.  Facilitates member second level appeal process.

EDUCATION/EXPERIENCE

Graduate from an accredited school of professional nursing is required.  BSN preferred.  Minimum 2 years acute care experience or managed care experience is required.  Basic knowledge of Medicaid, Medicare preferred.  Knowledge of InterQual screening criteria, ICD-10, CPT coding preferred.

LICENSURE

Current Registered Nurse (RN) license to practice professional nursing issued by the Board of Nurse Examiners for the State of Texas is required. Active Certification in Case Management (CCM) is preferred.