Medical Auditor RN - Appeals & Grievances

JOB SUMMARY · The Medical Nurse Auditor conducts reviews of medical records, financial information, and plan documentation to conduct thorough written reviews of appeals and grievances and reconsiderations using evidenced-based medical guidelines to determine appropriateness of services.
ESSENTIAL FUNCTIONS OF THE ROLE · Review clinical information for all appeals (pre-service and post-service denials) utilizing InterQual criteria & plan policies to determine medical necessity of services requested.
· Use knowledge of nursing process and pathophysiology to interpret the needs or requirements of members including all age ranges (newborn to elderly), inpatient/outpatient medical and behavioral settings, medical/surgical procedures, and pharmacology.
· Identify, escalate, and resolve complex cases or issues as required.
· Validate the accuracy of claim billing, reviewing complex claims and coding, · Provides support for complex cases or escalations within scope of licensure or refers to appropriate leadership.
· Identifies, documents, and communicates potential quality assurance for risk management issues as appropriate.
· Performs service recovery efforts to support provider and member satisfaction.
· Educate members and providers on the appeal process.
· Collaborate with Medical Director and third-party reviewers to determine medical necessity.
· Draft member and provider letters for denials and approvals.
· Annotate medical records.
· Support Grievance and Appeals Specialists team.
KEY SUCCESS FACTORS · Demonstrates a comprehensive understanding of Baylor Scott & White Health’s internal processes and procedures.
· Advanced understanding of healthcare modalities, pathophysiology, therapies and equipment, terminology, and medical coding.
· 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 in both writing and verbally.
· Interpersonal skills to interact with a wide range of constituencies.
· Must possess critical-thinking and problem-solving skills.
· Ability to balance multiple demands and respond to time constraints.
· Ability to analyze, understand, and act on clinical care documentation.
· General computer skills including, but not limited to, Microsoft Office and electronic medical records system(s).
Establishes and maintains proficient level of information system knowledge BENEFITS Our competitive benefits package includes the following Immediate eligibility for health and welfare benefits 401(k) savings plan with dollar-for-dollar match up to 5% Tuition Reimbursement PTO accrual beginning Day 1 Note: Benefits may vary based upon position type and/or level QUALIFICATIONS EDUCATION - Associate's Bachelor's is preferred.
MAJOR - Nursing EXPERIENCE - 3 Years of Experience CERTIFICATION/LICENSE/REGISTRATION - Registered Nurse (RN)