Secondary Review & Notification RN

Community Health Choice Inc. Community is a non-profit managed care organization MCO licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:

• Medicaid
• State of Texas Access Reform (STAR) program for low-income children and pregnant women
• Childrens Health Insurance Program (CHIP) for the children of low-income parents
• CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid
• STAR Health Insurance Marketplace Plans that offer individual health coverage, including preventive care, emergency services, prescription drugs, and hospitalization, available to all regardless of pre-existing conditions.

Community Health Choice HMO D-SNP, a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid, that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.

Improving Members experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.

Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System, Harris Health Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.

JOB SUMMARY

The Secondary Review and Notification RN is responsible for subsequent review of redeterminations related to LTSS service approvals, denials, increases, reductions, and terminations, as well as service planning and documentation to ensure appropriate services are rendered.

JOB SPECIFICATIONS AND CORE COMPETENCIES

• Responsible for secondary review of LTSS service approvals, denials, increases, reductions, and terminations, will provide feedback to confirm previous decisions or raise awareness when needed on decisions made by the SC and UM team.
• Complete and monitor letter generation and mailing accuracy of all adverse determination letters to ensure compliance while accurately entering the required information into the managed care platform, adhering to regulatory policies and procedures.
• Provide secondary support in the development and generation of adverse determination letters.
• Review of adverse determination letters for accuracy and appropriateness of Medical Director documentation to ensure compliance to all regulatory requirements prior to mailings.
• Actively contributes to achievement of departmental goals as identified in Departments annual business plan, including specific departmental process improvement plans and other duties as assigned.

QUALIFICATIONS

• Education: BSN preferred
• Licensure: Current unrestricted RN license in the state of Texas required
• Work Experience: 3 years clinical experience in a managed care organization, 3 years experience working in Utilization Management environment, 3 years experience working within applicable state, federal, and third-party regulatory agencies (i.e. CMS, HHSC, TDI, and Medicaid)
• Management Experience: None
• Software Proficiencies: Microsoft Office, Word, Excel, and Outlook