Appeal Specialist

Texas Children's Hospital•Bellaire, TX

About The Position

The Appeal Specialist educates and supports members through appeals, external medical review, and fair-hearing processes. The role serves as a primary point of contact, provides advocacy and timely communication, and helps ensure requests are processed accurately and in accordance with regulatory requirements. The position also supports collaboration across internal teams and delegated partners to resolve member and provider concerns and facilitate reviews and hearings.

Requirements

High school diploma or GED.
Community Health Worker certification issued by the Texas Department of State Health Services.
Four years of fundamental utilization management experience.

Nice To Haves

Two years of direct experience with utilization management prior authorizations, appeals, fair hearings, and external medical review.

Responsibilities

Educate members about their rights, responsibilities, benefits, complaints, appeals, external medical review, and fair-hearing processes.
Advocate for members by gathering necessary information and supporting appropriate representation throughout the resolution process.
Research complex concerns, collaborate with internal departments and external resources, and communicate resolution plans to affected parties.
Monitor real-time queues, adherence reports, service levels, response times, and escalation plans.
Collaborate with claims, eligibility, provider relations, business operations, and other teams to resolve member and provider concerns.
Translate member correspondence and documentation between English and Spanish, and provide medical interpretation for Spanish-speaking members and clinical staff.
Assist with referrals to case management, service coordination, and population health programs as needed.
Initiate and support external medical review and fair-hearing requests through applicable state systems.
Coordinate documentation with internal teams and delegated partners to support external medical review and fair-hearing requests.
Support medical leadership with external medical review and fair-hearing processes, and facilitate internal pre-fair-hearing meetings.
Monitor regulatory compliance, ensure determinations are implemented within required time frames, and submit required documentation to state agencies.
Document external medical review and fair-hearing activities accurately in utilization management systems.
Provide information for required internal and external reports.
Collect and verify member and provider information for prior authorization and appeal requests using available systems and resources.
Use medical terminology and coding knowledge to ensure information is complete for clinical review.
Identify process-improvement opportunities, support action plans, and participate in department projects and committees.