Denial and Appeal Coordinator

Texas Children's Hospital•Bellaire, TX

23h

About The Position

The Denial and Appeal Coordinator coordinates the clinical review and processing of appeals related to medical necessity decisions. The role partners with clinical reviewers, physician reviewers, providers, and members to support timely, accurate, and compliant appeal determinations. It also supports continuity-of-care needs, external reviews and fair hearings, appeal-related audits and reporting, and ongoing improvements to appeal processes.

Requirements

Diploma or associate degree in nursing; or an associate degree in a related field accepted by the Texas Board of Nursing for obtaining and maintaining a Registered Nurse license; or a bachelor's degree in nursing; or a master's degree in speech-language pathology, physical therapy, or occupational therapy.
An applicable license is required: Registered Nurse license issued by the Texas Board of Nursing or through the Nursing Licensure Compact; Physical Therapist or Occupational Therapist license issued by the applicable Texas licensing board; or Texas Speech-Language Pathologist license.
Three years of nursing, speech-language pathology, occupational therapy, physical therapy, utilization management, or related experience.

Responsibilities

Review appeals for compliance with applicable regulatory, accreditation, benefit, and decision-making requirements.
Collaborate with physician reviewers and clinical teams on appeal strategies, guideline citations, and responses.
Coordinate continuity-of-care needs and support authorization requests for out-of-network services when appropriate.
Identify appeal-process barriers and improvement opportunities, and implement improvements to support efficient, compliant case management.
Monitor appeal, external medical review, and fair-hearing decisions, timeliness, and processing requirements.
Communicate appeal status, due-process requirements, rationales, and decisions to members, authorized representatives, physicians, providers, and internal stakeholders.
Coordinate external medical review and fair-hearing requests, working with independent review organizations when specialty or external review is needed.
Maintain complete and accurate appeal records, including communications, case documentation, tracking information, and determination letters.
Document activities and interactions in electronic systems and generate appeal determination letters as appropriate.
Liaise with state agencies regarding independent review requests and required reporting.
Educate clinical review staff and physician reviewers about appeal-process changes, policies, procedures, managed care, and Medicaid requirements.
Audit appeal activities to support process integrity and compliance with established policies and procedures.
Assist with accreditation file reviews and develop corrective action plans based on audit findings.
Analyze appeal trends and prepare internal and external reports on appeal activity, resolutions, and timeliness standards.
Support required state reporting within established time frames.