Um Denial Coordinator Lvn

Founded in 1996, Texas Children's Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.

To join our community of 14,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org .

Texas Children's is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

Summary:

We are searching for a UM Denial Coordinator LVN - someone who works well in a fast-paced setting. In this position, using a collaborative approach, the licensed vocational nurse (LVN) denial coordinator will work with Texas Children's Health Plan (TCHP) medical directors/physician reviewers, network physicians, and network facilities to ensure consistent clinical evaluation and processing of cases not meeting TCHP medical necessity criteria for reasons of medical necessity decisions. Documentation of these decisions and precise record-keeping of notice to Members and network providers is essential in complying with the legal statute and accrediting standards supporting consumer rights.

Think you've got what it takes?

Qualifications:

Being fully vaccinated against COVID-19, including any booster dose(s) of the COVID-19 vaccine recommended by the Centers for Disease Control when eligible, is required for all employees at Texas Children's unless approved for a medical or religious exemption

• Required 5 years of Utilization Management experience and a preferred 3 years of Denial or Appeal experience
• Graduation from an accredited School of Vocational Nursing
• LVN - Lic-Licensed Vocational Nurses by the State of Texas

Responsibilities:

• Ensures the provision of continuity of care needs as required and serves as an advocate on behalf of members and families for out of network authorization approvals
• Assesses trends in denial types or sources quarterly
• Validates that authorizations requests are complete and if not, collaborate with UM Reviewers and Medical Directors for correction
• Ensures daily monitoring of the denial inquiries
• Serves as a liaison with the Texas Department of Insurance for independent review requests
• Maintains flexible schedule for some evenings and weekends to address potential pharmacy denials
• Implements action in collaboration with physician reviewer panel and monitors decision making, timeliness, and processing of denials in accordance to regulatory and accrediting guidelines
• Performs other duties, projects and actions as assigned
• Daily updates denial log information
• Serves as a Flex team - reviews authorization for inpatient and outpatient requests and processes per established criteria and or guidelines for the appropriate benefit, service, and level of care or setting for the delivery of care and or service
• Provides community education for other reviewers on guideline application, changes, and updates
• Teams with the physician team to identify a strategy for action and to be used as well as a choice of guideline citation/response based on the category of denial
• Documents all activities and interactions in the electronic and event tracking systems
• Collaborates with other reviewers, medical directors, external physician reviewers, and network providers
• Performs all necessary communication and documentation functions.
• Communicates with internal staff, physicians, hospital representatives, and other providers on status of case review and due process and explanation of rationale, process, and regulatory processing
• Analyzes requests against regulatory and decision-making guidelines and benefits allowance.
• Identifies problems/barriers/opportunities in the process and provides for resolution, and revision of plans on an ongoing basis
• Provides audits on physician and nursing staff based upon audit findings, developing coaching plans based upon findings
• Handles inquiries from providers and other departments in a professional manner.
• Established integrity of the review process of denial compliance and policies and procedures of the Texas Children's Health Plan, managed care, and Medicaid through informing and auditing practice
• Educates physician reviewers and nursing staff on policies and procedures of the Texas Children's Health Plan managed care and Medicaid
• Develops and analyzes quarterly reports for the Clinical Advisory Committee, Quality Improvement Committee, and TCHP Leadership to address outcome data to assist in the identification of improvement opportunities
• Create understandably worded letters, with added citation and criteria as applicable
• Reports denial activity type and resolution as well as achievement of timely communication standards
• Performs audits at least annually and quarterly for new hires
• Reviews cases sent by TCHP Utilization Reviewer to establish of criteria application and time frame of processing meet conditions for denial
• Ensure letters are sent in a timely manner to stay in regulatory compliance
• Conducts staff and medical director(s) audits on denial activities
• Generates letters as appropriate (approval, denial, appeal, peer to peer)
• Re-fax denial notifications or letters, respond to the provider or interdepartmental emails, and document in the referral notes as needed
• Collaborates with nurse reviewers, medical directors, external physician reviewers, and network providers
• Established integrity of the review process of denial compliance and policies and procedures, managed care and Medicaid through informing and auditing practice
• Communicates on each case with physicians to establish the best course of action