UM RN Appeals Coordinator - Work from Home

Sagility

8d • Remote

About The Position

About Sagility Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries. Job Description: BroadPath, a Sagility Company, is hiring UM RN Appeals Coordinator to join our remote team! Claims Processors are responsible for the accurate and timely entry, review, and resolution of medical claims ranging from simple to moderately complex. This includes reviewing front-end claims and validating information submitted by patients or providers seeking reimbursement from the insurance company. All claim processing must align with CMS guidelines and client-specific policies and procedures. Schedules, pay rates, and program details may vary based on business needs and client assignment.

Requirements

• RN license in an eNLC (Enhanced Nurse Licensure Compact) state with multistate privileges
• 3+ years Nursing experience
• 1+ years’ Utilization Management experience
• Familiarity with medical terminology, utilization management guidelines, and clinical documentation standards
• Proficiency in Microsoft Office and experience working with healthcare systems or electronic medical records
• Strong organizational and time management skills with the ability to work independently
• Excellent written and verbal communication 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

Responsibilities

• Performs necessary review to ensure compliance with HHSC and other regulatory entities
• Partners with the physician team to identify strategies for action and determine appropriate guideline citations or responses based on the category of denial
• 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
• Ensures continuity of care needs are met and advocates on behalf of Members and families for out-of-network authorization approvals
• Identifies problems, barriers, and opportunities within processes and develops resolutions or revisions as needed
• Conducts quarterly assessments of appeal status and program activities, preparing reports for both the State of Texas and internal review
• 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
• 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 systems
• Generates appeal determination letters as appropriate
• 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
• Assists with appeal file preparation for NCQA file reviews
• Supports the development of corrective action plans based on trended audit findings
• 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

Benefits

• Medical, Dental, and Vision coverage.
• Life Insurance.
• Short-Term and Long-Term Disability options.
• Flexible Spending Account (FSA).
• Employee Assistance Program.
• 401(k) with employer contribution.
• Paid Time Off (PTO).
• Tuition Reimbursement.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed