Denial and Appeal Coordinator

At our company, our mission starts with our people. Guided by our HEART values of Humility, Excellence, Accountability, Respect, and Trust, we strive to create a workplace where teammates feel valued, supported, and empowered to do their best work every day. As an Appeal Coordinator, you’ll coordinate the clinical review and processing of appeals related to medical necessity decisions. You’ll partner with clinical reviewers, physician reviewers, providers, and members to ensure timely, accurate, and compliant appeal determinations.

Job Duties & Responsibilities

• Reviews appeals to ensure compliance with applicable regulatory, accreditation, benefit, and decision-making requirements
• Collaborates with physician reviewers and clinical teams to determine appropriate appeal strategies, guideline citations, and responses
• Coordinates continuity-of-care needs and supports authorization requests for out-of-network services when appropriate
• Identifies appeal-process barriers and opportunities and implements improvements to support efficient, compliant case management
• Monitors appeal, external medical review, and fair-hearing decisions, timeliness, and processing requirements
• Communicates appeal status, due-process requirements, rationales, and decisions with members, authorized representatives, physicians, providers, and internal stakeholders
• Coordinates external medical review and fair-hearing requests and works with independent review organizations when specialty or external review is needed
• Maintains complete, accurate appeal records, including communications, case documentation, tracking information, and determination letters
• Documents activities and interactions in electronic systems and generates appeal determination letters as appropriate
• Serves as a liaison with state agencies for independent review requests and required reporting
• Educates clinical review staff and physician reviewers on appeal-process changes, policies, procedures, managed care, and Medicaid requirements
• Conducts audits of appeal activities to support process integrity and compliance with established policies and procedures
• Assists with accreditation file reviews and develops corrective action plans based on audit findings
• Analyzes appeal trends and prepares internal and external reports on appeal activity, resolutions, and timeliness standards
• Supports required state reporting within established time frames

Qualifications

• Diploma or associate degree in nursing required, or
• Associate degree in a related field accepted by the Texas Board of Nursing for obtaining and maintaining a Registered Nurse license required, or
• Bachelor’s degree in nursing required, or
• Master’s degree in speech-language pathology, physical therapy, or occupational therapy required
• Registered Nurse license issued by the Texas Board of Nursing or through the Nursing Licensure Compact required, or
• Physical Therapist or Occupational Therapist license issued by the applicable Texas licensing board required, or
• Texas Speech-Language Pathologist license required
• Three years of nursing, speech-language pathology, occupational therapy, physical therapy, utilization management, or related experience required

Job Duties & Responsibilities

• Reviews appeals to ensure compliance with applicable regulatory, accreditation, benefit, and decision-making requirements
• Collaborates with physician reviewers and clinical teams to determine appropriate appeal strategies, guideline citations, and responses
• Coordinates continuity-of-care needs and supports authorization requests for out-of-network services when appropriate
• Identifies appeal-process barriers and opportunities and implements improvements to support efficient, compliant case management
• Monitors appeal, external medical review, and fair-hearing decisions, timeliness, and processing requirements
• Communicates appeal status, due-process requirements, rationales, and decisions with members, authorized representatives, physicians, providers, and internal stakeholders
• Coordinates external medical review and fair-hearing requests and works with independent review organizations when specialty or external review is needed
• Maintains complete, accurate appeal records, including communications, case documentation, tracking information, and determination letters
• Documents activities and interactions in electronic systems and generates appeal determination letters as appropriate
• Serves as a liaison with state agencies for independent review requests and required reporting
• Educates clinical review staff and physician reviewers on appeal-process changes, policies, procedures, managed care, and Medicaid requirements
• Conducts audits of appeal activities to support process integrity and compliance with established policies and procedures
• Assists with accreditation file reviews and develops corrective action plans based on audit findings
• Analyzes appeal trends and prepares internal and external reports on appeal activity, resolutions, and timeliness standards
• Supports required state reporting within established time frames

Qualifications

• Diploma or associate degree in nursing required, or
• Associate degree in a related field accepted by the Texas Board of Nursing for obtaining and maintaining a Registered Nurse license required, or
• Bachelor’s degree in nursing required, or
• Master’s degree in speech-language pathology, physical therapy, or occupational therapy required
• Registered Nurse license issued by the Texas Board of Nursing or through the Nursing Licensure Compact required, or
• Physical Therapist or Occupational Therapist license issued by the applicable Texas licensing board required, or
• Texas Speech-Language Pathologist license required
• Three years of nursing, speech-language pathology, occupational therapy, physical therapy, utilization management, or related experience required