Denial and Appeal 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

Job Description

At our company, our mission starts with our people. Guided by our HEART values of Humility, Excellence, Accountability, Respect, and Trust, we strive to create a workplace where teammates feel valued, supported, and empowered to do their best work every day. As an Appeal Coordinator, you’ll coordinate the clinical review and processing of appeals related to medical necessity decisions. You’ll partner with clinical reviewers, physician reviewers, providers, and members to ensure timely, accurate, and compliant appeal determinations.

Job Duties & Responsibilities

• Reviews appeals to ensure compliance with applicable regulatory, accreditation, benefit, and decision-making requirements
• Collaborates with physician reviewers and clinical teams to determine appropriate appeal strategies, guideline citations, and responses
• Coordinates continuity-of-care needs and supports authorization requests for out-of-network services when appropriate
• Identifies appeal-process barriers and opportunities and implements improvements to support efficient, compliant case management
• Monitors appeal, external medical review, and fair-hearing decisions, timeliness, and processing requirements
• Communicates appeal status, due-process requirements, rationales, and decisions with members, authorized representatives, physicians, providers, and internal stakeholders
• Coordinates external medical review and fair-hearing requests and works with independent review organizations when specialty or external review is needed
• Maintains complete, accurate appeal records, including communications, case documentation, tracking information, and determination letters
• Documents activities and interactions in electronic systems and generates appeal determination letters as appropriate
• Serves as a liaison with state agencies for independent review requests and required reporting
• Educates clinical review staff and physician reviewers on appeal-process changes, policies, procedures, managed care, and Medicaid requirements
• Conducts audits of appeal activities to support process integrity and compliance with established policies and procedures
• Assists with accreditation file reviews and develops corrective action plans based on audit findings
• Analyzes appeal trends and prepares internal and external reports on appeal activity, resolutions, and timeliness standards
• Supports required state reporting within established time frames

Qualifications

• Diploma or associate degree in nursing required, or
• Associate degree in a related field accepted by the Texas Board of Nursing for obtaining and maintaining a Registered Nurse license required, or
• Bachelor’s degree in nursing required, or
• Master’s degree in speech-language pathology, physical therapy, or occupational therapy required
• Registered Nurse license issued by the Texas Board of Nursing or through the Nursing Licensure Compact required, or
• Physical Therapist or Occupational Therapist license issued by the applicable Texas licensing board required, or
• Texas Speech-Language Pathologist license required
• Three years of nursing, speech-language pathology, occupational therapy, physical therapy, utilization management, or related experience required

About Us

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.

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.