About Us

We at Baylor Scott & White Health promote the well-being of people, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas, empowering you to live well.

Our Core Values are:

• We serve faithfully by doing what's right with a joyful heart.
• We never settle by constantly striving for better.
• We are in it together by supporting one another and those we serve.
• We make an impact by taking initiative and delivering exceptional experience.

Benefits

Our competitive benefits package empowers you to live well and provides:

• Eligibility on day 1 for all benefits
• Dollar-for-dollar 401(k) match, up to 5%
• Debt-free tuition assistance, offering access
  to many no-cost and low-cost degrees, certificates and more
• Immediate access to time off benefits

At Baylor Scott & White Health, your well-being is our top priority.

Note: Benefits may vary based on position type and/or level

JOB SUMMARY

HYBRID POSITION

The Appeals & Grievances (Medical Auditor) RN conducts reviews of medical records, and plan documentation to conduct thorough written reviews of appeals, grievances, and reconsiderations using evidence-based medical guidelines to assist the Medical Director in determining the appropriateness of services.

ESSENTIAL FUNCTIONS OF THE ROLE

• Reviews clinical information for appeals and grievances (pre- and post-service denials) utilizing evidence-based medical criteria & plan policies.
• Extrapolates and concisely summarizes essential medical information for the Health Plan's Medical Directors and other reviewers.
• Uses knowledge of nursing process and pathophysiology to present a concrete, objective, and cohesive evaluation of members' dispute of adverse determinations, including all age ranges (newborn to elderly), inpatient/outpatient medical and behavioral settings, medical/surgical procedures, and pharmacology.
• Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
• Ability to differentiate types of requests- appeals, grievances, and organization determinations, to ensure the correct processing of the issue.
• Identifies, escalates, and/or provides support for complex cases for referral to Case Management or Quality Improvement Department if a Quality of Care issue is identified.
• At times, may be called upon to educate members and providers on the appeal process.
• Documents accurately and comprehensively based on the standards of practice and current organization policies by drafting member and provider letter language for denials and approvals and appropriately annotating appeal records.
• Collaborates with leadership to provide orientation and ongoing education of new department employees.
• Clinical acumen to criticallythink and be able to quickly and objectively pull together relevant information.
• Participates in process improvement projects, including the evaluation, development and implementation of protocols, policies, and procedures to continuously enrich care coordination efforts and ensure evidence-based processes are utilized.
• Availability to work outside of standard business hours (evenings, weekends, and holidays) to meet regulatory timeframes.
• Demonstrates flexibility to understand the regulatory requirements needed to process the clinical appeal inclusive of peer to peer; resolution language in layman terms or reading level; and inherent turnaround times (as little as 72 hours).

KEY SUCCESS FACTORS

• Current, active, unrestricted RN license to practice as a health professional within the scope of practice in the State of Texas and minimum 2 years acute care clinical experience.
• Bachelor of Science in Nursing or equivalent experience preferred.
• Experience in Utilization Management and/or Case Management preferred.
• Demonstrates a comprehensive understanding of Baylor Scott & White Health's internal processes and procedures.
• Advanced understanding of healthcare modalities, pathophysiology, therapies and equipment, and medical terminology.
• 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 both in writing and verbally.
• Interpersonal skills to interact with a wide range of constituencies.
• Must possess critical-thinking and problem-solving skills with a strong ability to research evidence-based practices.
• Ability to balance multiple demands and respond to time constraints and regulatory changes that need to be incorporated and learned quickly.
• Ability to analyze, understand, and consolidate clinical documentation.
• General computer skills including, but not limited to, Microsoft Office, electronic medical records system(s), and InterQual.
• Establishes and maintains proficient level of information system knowledge.

Qualifications

• Possess an Associate's degree in Nursing
• Have at least 3 years of relevant work experience
• Hold a Registered Nurse license