Clinical Appeals Coordinator

Texas Children's Hospital; Bellaire (TX); On-site; USD 65,000 - 85,000; Full time

Job summary

Texas Children’s Health Plan is seeking an Appeal Coordinator to manage clinical review and processing of medical-necessity appeals. You will partner with clinical reviewers, physicians, providers, and members to ensure timely, accurate, and compliant determinations.

Primary duties include coordinating strategies, ensuring regulatory alignment, maintaining complete records, and communicating decisions to all stakeholders.

Qualifications

• Nursing license in Texas or via Nursing Licensure Compact.
• Diploma or associate degree in nursing.
• Bachelor’s degree in nursing.
• Master’s degree in speech-language pathology, physical therapy, or occupational therapy.
• Three years of nursing, SLP, OT, PT, utilization management, or related experience.
• Texas RN license or applicable PT/OT license.
• Texas Speech-Language Pathologist license.

Responsibilities

• Reviews appeals to ensure regulatory and policy compliance.
• Collaborates with physician reviewers to determine appeal strategies and citations.
• Coordinates continuity-of-care needs and authorizations for out-of-network services when appropriate.
• Identifies barriers and implements process improvements for efficient case management.
• Monitors timeliness and processing requirements for appeals and reviews.
• Communicates appeal status and rationales to members, providers, and stakeholders.
• Coordinates external medical review and fair-hearing requests with independent review organizations as needed.
• Maintains complete appeal records and generates determination letters.
• Documents activities in electronic systems and generates letters as appropriate.
• Serves as liaison with state agencies for independent review requests and reporting.
• Educates staff on appeal-process changes and Medicaid requirements.
• Conducts audits to ensure policy compliance.
• Assists with accreditation file reviews and corrective action plans.
• Analyzes appeal trends and prepares internal/external reports.
• Supports state reporting within established timeframes.

Skills

Healthcare coordination

Regulatory compliance

Provider/member communication

Education

Nursing Diploma or Associate degree

Bachelor’s degree in nursing

Master’s degree in SLP, PT, or OT

Texas RN license or Nursing Licensure Compact

Texas Speech-Language Pathologist license

Three years of nursing/SLP/OT/PT/utilization management experience

Job description

Texas Children’s Health Plan is seeking an Appeal Coordinator to manage clinical review and processing of medical-necessity appeals. You will partner with clinical reviewers, physicians, providers, and members to ensure timely, accurate, and compliant determinations.

Primary duties include coordinating strategies, ensuring regulatory alignment, maintaining complete records, and communicating decisions to all stakeholders.