JOB SUMMARY: The Appeals Nurse assists in the review of medical records submitted for appeals by providers due to adverse determination. Utilize evidence based criteria, regulatory guidelines and Medical Affairs departmental policies for medical necessity and level of care determination. Provides written response of the outcome of the appeals finding to the appealing provider and member. Assists in the ongoing development and maintenance of a database for tracking, trending and reporting appeals cases.MINIMUM QUALIFICATIONS:1. Education/Specialized Training/Licensure: Registered Nurse, current Texas License2. Work Experience : One (1) year of experience utilizing evidence based criteria in medical review
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