Appeals and Grievance Registered Nurse Lead
Christus Health

Houston, Texas


Summary:

The Lead must demonstrate a consistently high degree of proficiency in their position within the Clinical Appeals Department of CHRISTUS Health. The Lead is responsible for a variety of activities in the department. The primary purpose of this role is to allow for professional growth and development within the organization, while applying one's expertise and knowledge within the department. The position provides opportunities to increase one's scope of responsibility within the Clinical Appeal Department. The position works in a cooperative team environment to provide value, works in partnership with the management team and serves as a resource for innovation, staff support and process improvements. A Lead must be able to meet the accountabilities outlined below.

  • Functions as a subject matter expert in support of other Clinical Appeals team members and other departments/facilities within the CHRISTUS Health network.
  • Trains new staff in all areas as needed and provides source of knowledge for staff inquiries. - Adapt to process and procedure evaluations and improvements, support continuous change, and willingly manage special projects in addition to normal workload and other duties.
  • Remain flexible to best serve Clinical Appeals and CHRISTUS Health.
  • Display a professional, courteous and enthusiastic demeanor, while maintaining a positive self image and perspective of the unit/company.
  • Ensures quality and productivity standards are met or exceeded.
  • Functions effectively within a team and participates and contributes constructively to produce results in a cooperative effort.
  • Demonstrates ongoing enthusiasm and commitment to the work assigned.
  • Works with director to receive feedback on performance and create a personal development plan.
  • Focuses on the review and analysis of governmental denial rationales and provides appropriate medical necessity appeal services
  • Review governmental contractors response letter in comparison to the medical records.
  • Communicates with facility regarding missing or insufficient medical documentation - Review medical documentation for adherence to Medicare guidelines relating to inpatient services (or other Medicare issues) and draft appropriate appeal letters based upon professional clinical opinion as to the medical necessity of the services provided. - Research issues using law, federal regulations, and relevant CMS policies
  • Communicates with members of the healthcare team identifying root causes for potential denials
  • Communicates with the CMO/VPMA regarding appeals and obtain signature for appeals
  • Assures all discussions and appeals are filed timely
  • Completes data entry in the Denial database for tracking, trends, and analysis
Requirements:
  • Two years' experience working within the Clinical Appeals department required
  • RN License in state of employment or compact
Work Type:

Full Time


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