About Us

We at Baylor Scott & White Health promote the well-being of people, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas, empowering you to live well.

Our Core Values are:

• We serve faithfully by doing what's right with a joyful heart.
• We never settle by constantly striving for better.
• We are in it together by supporting one another and those we serve.
• We make an impact by taking initiative and delivering exceptional experience.

Benefits

Our competitive benefits package empowers you to live well and provides:

• 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

At Baylor Scott & White Health, your well-being is our top priority. 

Note: Benefits may vary based on position type and/or level

JOB SUMMARY

HYBRID 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.

ESSENTIAL FUNCTIONS OF THE ROLE

• 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, including all age ranges (newborn to elderly), inpatient/outpatient medical and behavioral settings, medical/surgical procedures, and pharmacology.
• 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. 
• Clinical acumen to critically think and be able to quickly and objectively pull together relevant information.
• 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.
• Availability to work outside of standard business hours (evenings, weekends, and holidays) to meet regulatory timeframes.  
• Demonstrates flexibility to understand the regulatory requirements needed to process the clinical appeal inclusive of peer to peer; resolution language in layman terms or reading level; and inherent turnaround times (as little as 72 hours). 

KEY SUCCESS FACTORS

• Current, active, unrestricted RN license to practice as a health professional within the scope of practice in the State of Texas and minimum 2 years acute care clinical experience.
• Bachelor of Science in Nursing or equivalent experience preferred.
• Experience in Utilization Management and/or Case Management preferred.
• Demonstrates a comprehensive understanding of Baylor Scott & White Health?s internal processes and procedures.
• Advanced understanding of healthcare modalities, pathophysiology, therapies and equipment, and medical terminology.
• Knowledge of applicable federal and state regulatory requirements including TDI, CMS, DOL, HHSC, and NCQA standards and requirements, and others as applicable.
• Clear communication of thoughts both in writing and verbally.
• Interpersonal skills to interact with a wide range of constituencies.
• Must possess critical-thinking and problem-solving skills with a strong ability to research evidence-based practices.
• Ability to balance multiple demands and respond to time constraints and regulatory changes that need to be incorporated and learned quickly.
• Ability to analyze, understand, and consolidate clinical documentation.
• General computer skills including, but not limited to, Microsoft Office, electronic medical records system(s), and InterQual.
• Establishes and maintains proficient level of information system knowledge.

Qualifications

• Possess an Associate's degree in Nursing
• Have at least 3 years of relevant work experience
• Hold a Registered Nurse license

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About Baylor Scott & White Health

Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!

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