UM RN Appeals Coordinator

Overview

BroadPath is seeking a highly motivated and results-driven UM RN Appeals Coordinator. This role collaborates with clinical review staff, medical directors / physician reviewers, network physicians, and network facilities to ensure consistent clinical evaluation and processing of medical necessity appeals. Accurate documentation and detailed recordkeeping of notifications to members and network providers are critical to maintaining compliance with legal and accreditation standards and upholding consumer rights.

Compensation Highlights :

Base Pay : up to $50.00 per hour

Pay Frequency : Weekly

Schedule Highlights :

Training Schedule : 2 weeks, Monday - Friday; 8 : 00 AM - 5 : 00 PM CST

Production Schedule : Monday - Friday; 8 : 00 AM -5 : 00 PM CST (Flexible)

Responsibilities

A. Performs necessary review to ensure compliance with HHSC and other regulatory entities

Collaborate : Partners with the physician team to identify strategies for action and determine appropriate guideline citations or responses based on the category of denial

Develop : Creates training materials and examples for nursing staff to enhance understanding of criteria application, benefit use, and the appeal, External Medical Review (EMR), and Fair Hearing processes

Coordinate : Ensures continuity of care needs are met and advocates on behalf of Members and families for out-of-network authorization approvalsImplement : Identifies problems, barriers, and opportunities within processes and develops resolutions or revisions as needed

Evaluate : Conducts quarterly assessments of appeal status and program activities, preparing reports for both the State of Texas and internal review

Analyze : Reviews requests against regulatory and decision-making guidelines and benefit allowances, implements actions in collaboration with the physician reviewer panel, and monitors timeliness, decision-making, and processing of appeals, EMRs, and State Fair Hearings in accordance with regulatory and accrediting standards

B. Performs all necessary communication and documentation functions

Communicates with internal staff, Members / LARs, physicians, hospital representatives, and other

Providers regarding case status, due process, rationale, and regulatory requirements

Coordinates Fair Hearing requests through TIERS when a Member / LAR or Provider requests an EMR or Fair Hearing

Utilizes an Independent Review Organization as needed for specialty or external reviews

Oversees documentation and recordkeeping of all case communications in compliance with accrediting requirements

Documents all activities and interactions in electronic and event tracking systemsGenerates appeal determination letters as appropriate

C. Collaborates with clinical reviewers, medical directors, external physician reviewers, and network Providers

Communicates with physicians on each case to establish the most appropriate course of action

Provides education to nurse and therapist reviewers regarding appeal updates and process changes

Maintains flexibility in scheduling, including evenings and weekends, to address pharmacy-related denials

Educates physician reviewers and clinical review staff on managed care and Medicaid policies and procedures

D. Conducts staff and medical director audits on appeal activities

Assists with appeal file preparation for NCQA file reviews

Supports the development of corrective action plans based on trended audit findings

E. Provides data for internal and external reporting

Analyzes quarterly trends in appeal types and sources

Reports appeal activity, type, and resolution, ensuring timely communication standards are met

Assists with state reporting in the required format and ensures timely submission to HHSC to avoid financial penalties

Knowledge and Skills

Demonstrates proficiency in applying advanced principles, concepts, and techniques central to nursing and ancillary therapy services within managed care, with emphasis on complex pediatrics and obstetrics

Ability to comprehensively assess Member and family medical needs, develop and implement plans of care, provide ongoing evaluation and monitoring, and deliver education to Members, families, Providers, and staff

Exemplary verbal and written communication skills, with proficiency in computer operation, word processing programs, fax machines, photocopiers, and multi-line telephones

Strong customer service orientation and advanced interpersonal communication skills with all levels of internal and external stakeholders, including medical staff, patients and families, clinical personnel, support staff, outside agencies, and community partners

Qualifications

RN license for the state of Texas or compact license

3+ years Nursing experience

1+ years Utilization Management and Appeals experience

Excellent verbal, written and computer skills

Highly motivated with ability to work independently

Strong team player mindset

Diversity Statement

At BroadPath, diversity is our strength. We embrace individuals from all backgrounds, experiences, and perspectives. We foster an inclusive environment where everyone feels valued and empowered. Join us and be part of a team that celebrates diversity and drives innovation!

Equal Employment Opportunity / Disability / Veterans

If you need accommodation due to a disability, please email us at HR@Broad-path.com . This information will be held in confidence and used only to determine an appropriate accommodation for the application process.

BroadPath is an Equal Opportunity Employer. We do not discriminate against our applicants because of race, color, religion, sex (including gender identity, sexual orientation, and pregnancy), national origin, age, disability, veteran status, genetic information, or any other status protected by applicable law.

Compensation : BroadPath has an effective process for assessing market data and establishing ranges to ensure we remain competitive. You are paid within the salary range based on your experience and market data of the position. The actual salary for this role may vary by location.