Texas Health Resources Clinical Review Registered Nurse / Denials and Appeals - Full Time - Arlington in Arlington, Texas
Texas Health Resources is seeking to hire a Clinical Review Registered Nurse / Denials and Appeals for our Clinical Review and Denials Department.
The location is the Chase Building located at – 500 East Border Street, Arlington, Texas 76010.
Salary range is $35.48/hour – Max $49.18/hour – based on relevant experience.
• Full Time, Day Shift
The Clinical Review Utilization Manager is responsible for communicating and collaborating as needed with physicians, Care Management staff, Business Office, Nursing, and ancillary departments to proactively address patient care issues and denials management. The essential job functions for this position are:
• Conducts the necessary research for appealing denied days/stays through electronic record review. Requires access to Care Connect patient records for all THR hospitals.
• Reviews clinical documentation in order to determine if medical necessity criteria were met.
• Collaborates with physicians when needed to develop comprehensive and effective appeal strategies for medical necessity denials.
• Prepares appeal letters and notifications to appropriate parties and hospital departments within the specified time frames and files appeal per contracted agreement.
• Tracks, monitors, manage clinical denials and appeals and appeal outcomes for reporting as requested.
• Reports denial trends to the respective departments are used for educational corrective action.
• Develops and maintains relationships with other departments related to appeals and denial management.
• Serves as an educator and resource to the Care Management Staff, Physicians and other hospital disciplines as required/designated regarding Medicare, Medicaid and Commercial payer guidelines.
• Performs retrospective commercial insurance reviews.
• Reviews Medicare one day stays and conducts medical necessity internal audits (100% one day stays)
• Performs other duties as assigned.
The ideal candidate will possess the following qualifications:
• Bachelor’s Degree in Nursing preferred.
• 3 years inpatient clinical nursing experience in an acute hospital setting required And
• 1 year Utilization Management including knowledge and application of Milliman or Interquel criteria required.
• Experience in case management preferred.
• Registered Nurse License to practice professional nursing in the state Texas upon hire required.
• Analytical ability to collect information from diverse sources, apply professional principles in performing various analyses and summarize the information and data in order to solve problems.
• Ability to utilize comprehensive computer and database skills to streamline work and communicate to other team members, examples include but are not limited to e-mail, Word, Excel, medical necessity criteria.
• Analytical ability to resolve complex problems requiring use of basic scientific or technical principles and in-depth, experience-based knowledge.
• Ability to be articulate in both oral and written communications.
Why Texas Health Resources?
Texas Health Resources is one of the largest faith-based, nonprofit health care delivery systems in the United States and the largest in North Texas in terms of patients served. Texas Health has 25 acute-care and short-stay hospitals that are owned, operated, joint-ventured or affiliated with the system. It has more than 3,800 licensed beds, more than 21,100 employees of fully-owned/operated facilities plus 1,400 employees of consolidated joint ventures, and counts more than 5,500 physicians with active staff privileges at its hospitals.
At Texas Health, we strive to create an atmosphere of respect, integrity, compassion and excellence for all who come in contact with us, be they patients or our employees. We are committed to diversity in our workforce, and our mission to serve spreads across ethnic, cultural, economic and generational boundaries. We invite you to join us in furthering your career and our accomplishments and philosophy of excellence.
Texas Health Highlights
• 2019 FORTUNE Magazine’s “100 Best Companies to Work For®” (5 th year in a row)
• 2019 Becker's Healthcare "150 Great Places to Work in Healthcare" (5 th year in a row)
• 2019 Employees’ Choice “Best Places to Work” by Glassdoor
Employment opportunities are only reflective of wholly owned Texas Health Resources entities.
We are an Equal Opportunity Employer and do not discriminate against any employees or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.