About Us

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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.

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Our Core Values are:

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

Benefits

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

\n\nEligibility on day 1 for all benefits\nDollar-for-dollar 401(k) match, up to 5%\nDebt-free tuition assistance, offering access
to many no-cost and low-cost degrees, certificates and more\nImmediate access to time off benefits\n\n

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

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

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JOB SUMMARY

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HYBRID POSITION

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       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.

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ESSENTIAL FUNCTIONS OF THE ROLE

\n\nReviews clinical information for appeals and grievances (pre- and post-service denials) utilizing evidence-based medical criteria & plan policies.\nExtrapolates and concisely summarizes essential medical information for the Health Plan’s Medical Directors and other reviewers.\nUses 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. \nEnsures that appeals and grievances are resolved timely to meet regulatory timeframes.\nAbility to differentiate types of requests- appeals, grievances, and organization determinations, to ensure the correct processing of the issue.\nIdentifies, 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. \nAt times, may be called upon to educate members and providers on the appeal process.  \nDocuments 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. \nCollaborates with leadership to provide orientation and ongoing education of new department employees. \nClinical acumen to critically think and be able to quickly and objectively pull together relevant information.\nParticipates 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.\nAvailability to work outside of standard business hours (evenings, weekends, and holidays) to meet regulatory timeframes.  \nDemonstrates 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). \n\n

 

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KEY SUCCESS FACTORS

\n\nCurrent, 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. \nBachelor of Science in Nursing or equivalent experience preferred. \nExperience in Utilization Management and/or Case Management preferred. \nDemonstrates a comprehensive understanding of Baylor Scott & White Health’s internal processes and procedures.\nAdvanced understanding of healthcare modalities, pathophysiology, therapies and equipment, and medical terminology.\nKnowledge of applicable federal and state regulatory requirements including TDI, CMS, DOL, HHSC, and NCQA standards and requirements, and others as applicable. \nClear communication of thoughts both in writing and verbally.\nInterpersonal skills to interact with a wide range of constituencies.\nMust possess critical-thinking and problem-solving skills with a strong ability to research evidence-based practices.\nAbility to balance multiple demands and respond to time constraints and regulatory changes that need to be incorporated and learned quickly. \nAbility to analyze, understand, and consolidate clinical documentation. \nGeneral computer skills including, but not limited to, Microsoft Office, electronic medical records system(s), and InterQual. \nEstablishes and maintains proficient level of information system knowledge.\n\n

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Qualifications

\n\nPossess an Associate's degree in Nursing\nHave at least 3 years of relevant work experience\nHold a Registered Nurse license\n