Complaint and Appeals Nurse, El Paso Health - University Medical Center of El Paso
El Paso, TX 79905
About the Job
Job Summary
Reviews and prepares cases received from Members, Providers, the Texas Health and Human Services Commission (HHSC), the Texas Department of Insurance (TDI), the Centers for Medicare and Medicaid Services (CMS) and URAC to ensure that the review of an appeal or grievance case is completed and accomplished within the required timeframes. Works closely with other departments in the organization to ensure accurate entry of a case for tracking/documentation purposes. Works closely with the Medical Director as well as the following departments: Health Services and Claims to ensure that appeals and grievances are responded to appropriately and completely. Assists in the development of strategies and methodologies for specific process improvement initiatives to ensure efficiency and effectiveness.
Skills
1. Strong interpersonal, verbal and written communication skills
2. Strong problem-solving skills, implementing initiatives or projects, and collaborating with other professional and non-clinical staff.
3. Ability to interpret policies and procedures and communicate complex topics effectively.
4. Effective communication skills with a diverse audience to include customers, providers and vendors.
5. Excellent skills in researching and interpreting data.
6. Strong knowledge of the MS Office suite (Microsoft Excel, Word and Power Point programs).
7. Ability to work independently and exercise sound judgment in interactions with physicians, payors, and members/families.
8. Great attention to detail.
9. Ability to multitask, prioritize and manage time efficiently.
10. Bilingual, English and Spanish highly preferred.
Work Experience
Two years of health care experience required, preferably in a managed care environment in related area of responsibility, i.e. utilization management, quality management, grievances and appeals.
License/Registration/Certification
Current, active, unrestricted license to practice as a Registered Nurse or Licensed Vocational Nurse in the State of Texas required.
Education and Training
Associate degree in Nursing or License Vocational Nurse program. Bachelor degree in Nursing preferred.
PI251057369