JOB SUMMARY

STAR +PLUS 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

• Reviews and provides resolution of STAR+PLUS 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 clinical platform 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.
• Demonstrates Harris Health and Community Health Choice values, including trust, integrity, mutual respect, diversity, responsiveness and caring service.

MINIMUM 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; One (1) year in acute care setting or managed care setting , 1-3 years STAR+ PLUS experience required.
• Appeals Experience preferred.
• Software Proficiencies: Microsoft Office (Word, Excel, Access and Outlook)