Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion.
PRIMARY PURPOSE: Parkland Community Health Plan's (PCHP's) Clinical Appeals Nurse is responsible for performing clinical appeals and ensuring the appeals are timely and consistent. Collaborates with utilization management staff and medical director's appeals and grievances to determine care is provided in accordance with clinical guidelines and organizational standards.
- (3) Three years of experience in an acute clinical nursing or medical management setting.
- Experience with all levels of appeals is preferred.
- Experience in Texas Medicaid and NCQA is preferred.
Equivalent Education and/or Experience:
- May have an equivalent combination of education and experience to substitute for the experience requirements.
- Must have a current, unrestricted RN license to practice nursing in the State of Texas (or compact license).
Skills or Special Abilities:
- Clear and professional written and verbal communication skills.
- Proficient in medical and managed care terminology.
- Able to be flexible and work in a high growth environment.
- Excellent organizational skills and attention to detail.
- Ability to analyze and resolve complex and conflicting information.
- Able to develop and foster positive interpersonal relationships to effectively communicate and engage all levels of stakeholders.
- Ability to define Utilzation Management and Clinical Appeals reporting requirements is preferred.
- Adept in use of medical management software; CCA and QNXT are preferred.
- Prepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions; ensures all cases are completed in accordance with state and federal regulatory requirements including timelines.
- Presents recommendations based on clinical review, criteria and organizational policies to the medical directors for final determinations.
- Resolves complex and sensitive member issues within established timelines.
- Maintains departmental database and record integrity by accurately entering the case actions to the assigned cases.
- Oversees and participates in state fair hearings
- Assists with notification process to members and providers on the clinical decisions issues.
- Writes clear and concise grammatically correct appeals letters in PCHP format and standards.
- Participates in preparation of clear and concise audit reports.
- Identifies clinical documentation issues and provide proactive recommendations to managment.
1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.
Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.