UM RN Appeals Coordinator - Work from Home

Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries.Job title:UM RN Appeals Coordinator - Work from HomeJob Description:About SagilitySagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries.Job Description:BroadPath, a Sagility Company, is hiring UM RN Appeals Coordinator to join our remote team! Claims Processors are responsible for the accurate and timely entry, review, and resolution of medical claims ranging from simple to moderately complex. This includes reviewing front-end claims and validating information submitted by patients or providers seeking reimbursement from the insurance company. All claim processing must align with CMS guidelines and client-specific policies and procedures. Schedules, pay rates, and program details may vary based on business needs and client assignment.Compensation HighlightsBase Pay: up to $50 per hourPay frequency: Weekly paySchedule HighlightsTraining Schedule: 2 weeks, Monday – Friday; 8:00 AM - 5:00 PM CST Production Schedule: Monday – Friday; 8:00 AM - 5:00 PM CST (Flexible) ResponsibilitiesA. Performs necessary review to ensure compliance with HHSC and other regulatory entitiesCollaborate: Partners with the physician team to identify strategies for action and determine appropriate guideline citations or responses based on the category of denialDevelop: Creates training materials and examples for nursing staff to enhance understanding of criteria application, benefit use, and the appeal, External Medical Review (EMR), and Fair Hearing processesCoordinate: Ensures continuity of care needs are met and advocates on behalf of Members and families for out-of-network authorization approvalsImplement: Identifies problems, barriers, and opportunities within processes and develops resolutions or revisions as neededEvaluate: Conducts quarterly assessments of appeal status and program activities, preparing reports for both the State of Texas and internal reviewAnalyze: Reviews requests against regulatory and decision-making guidelines and benefit allowances, implements actions in collaboration with the physician reviewer panel, and monitors timeliness, decision-making, and processing of appeals, EMRs, and State Fair Hearings in accordance with regulatory and accrediting standardsB. Performs all necessary communication and documentation functionsCommunicates with internal staff, Members/LARs, physicians, hospital representatives, and otherProviders regarding case status, due process, rationale, and regulatory requirementsCoordinates Fair Hearing requests through TIERS when a Member/LAR or Provider requests an EMR or Fair HearingUtilizes an Independent Review Organization as needed for specialty or external reviewsOversees documentation and recordkeeping of all case communications in compliance with accrediting requirementsDocuments all activities and interactions in electronic and event tracking systemsGenerates appeal determination letters as appropriateC. Collaborates with clinical reviewers, medical directors, external physician reviewers, and network ProvidersCommunicates with physicians on each case to establish the most appropriate course of actionProvides education to nurse and therapist reviewers regarding appeal updates and process changesMaintains flexibility in scheduling, including evenings and weekends, to address pharmacy-related denialsEducates physician reviewers and clinical review staff on managed care and Medicaid policies and proceduresD. Conducts staff and medical director audits on appeal activitiesAssists with appeal file preparation for NCQA file reviewsSupports the development of corrective action plans based on trended audit findingsE. Provides data for internal and external reportingAnalyzes quarterly trends in appeal types and sourcesReports appeal activity, type, and resolution, ensuring timely communication standards are metAssists with state reporting in the required format and ensures timely submission to HHSC to avoid financial penaltiesKnowledge and SkillsDemonstrates proficiency in applying advanced principles, concepts, and techniques central to nursing and ancillary therapy services within managed care, with emphasis on complex pediatrics and obstetricsAbility to comprehensively assess Member and family medical needs, develop and implement plans of care, provide ongoing evaluation and monitoring, and deliver education to Members, families, Providers, and staffExemplary verbal and written communication skills, with proficiency in computer operation, word processing programs, fax machines, photocopiers, and multi-line telephonesStrong customer service orientation and advanced interpersonal communication skills with all levels of internal and external stakeholders, including medical staff, patients and families, clinical personnel, support staff, outside agencies, and community partnersQualificationsRN license in an eNLC (Enhanced Nurse Licensure Compact) state with multistate privileges3+ years Nursing experience1+ years’ Utilization Management experienceFamiliarity with medical terminology, utilization management guidelines, and clinical documentation standardsProficiency in Microsoft Office and experience working with healthcare systems or electronic medical recordsStrong organizational and time management skills with the ability to work independentlyExcellent written and verbal communication skillsAt BroadPath, a Sagility Company, we believe that transparency, authenticity, and collaboration are the keys to building strong, connected remote teams. If you are someone who values open communication, connection, and teamwork, you will thrive in our environment where showing up authentically matters.Benefits:Medical, Dental, and Vision coverage.Life Insurance.Short-Term and Long-Term Disability options.Flexible Spending Account (FSA).Employee Assistance Program.401(k) with employer contribution.Paid Time Off (PTO).Tuition Reimbursement.BroadPath, a Sagility Company, may conduct background checks, previous employment verifications, and education verifications, based on position requirementsDiversity StatementAt BroadPath, a Sagility Company, diversity is our strength. We embrace individuals from all backgrounds, experiences, and perspectives. We foster an inclusive environment where everyone feels valued and empowered. Join us and be part of a team that celebrates diversity and drives innovation!Equal Employment Opportunity/Disability/Veterans If you need accommodation due to a disability, please email us at HR@Broad-path.com. This information will be held in confidence and used only to determine an appropriate accommodation for the application process BroadPath, a Sagility Company is an Equal Opportunity Employer. We do not discriminate against our applicants because of race, color, religion, sex (including gender identity, sexual orientation, and pregnancy), national origin, age, disability, veteran status, genetic information, or any other status protected by applicable law. Compensation: BroadPath a Sagility Company has an effective process for assessing market data and establishing ranges to ensure we remain competitive. You are paid within the salary range based on your experience and market data of the position. The actual salary for this role may vary by location. Location:Work@Home USAUnited States of AmericaOriginally posted on Himalayas

Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries.Job title:UM RN Appeals Coordinator - Work from HomeJob Description:About SagilitySagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries.Job Description:BroadPath, a Sagility Company, is hiring UM RN Appeals Coordinator to join our remote team! Claims Processors are responsible for the accurate and timely entry, review, and resolution of medical claims ranging from simple to moderately complex. This includes reviewing front-end claims and validating information submitted by patients or providers seeking reimbursement from the insurance company. All claim processing must align with CMS guidelines and client-specific policies and procedures. Schedules, pay rates, and program details may vary based on business needs and client assignment.Compensation HighlightsBase Pay: up to $50 per hourPay frequency: Weekly paySchedule HighlightsTraining Schedule: 2 weeks, Monday – Friday; 8:00 AM - 5:00 PM CST Production Schedule: Monday – Friday; 8:00 AM - 5:00 PM CST (Flexible) ResponsibilitiesA. Performs necessary review to ensure compliance with HHSC and other regulatory entitiesCollaborate: Partners with the physician team to identify strategies for action and determine appropriate guideline citations or responses based on the category of denialDevelop: Creates training materials and examples for nursing staff to enhance understanding of criteria application, benefit use, and the appeal, External Medical Review (EMR), and Fair Hearing processesCoordinate: Ensures continuity of care needs are met and advocates on behalf of Members and families for out-of-network authorization approvalsImplement: Identifies problems, barriers, and opportunities within processes and develops resolutions or revisions as neededEvaluate: Conducts quarterly assessments of appeal status and program activities, preparing reports for both the State of Texas and internal reviewAnalyze: Reviews requests against regulatory and decision-making guidelines and benefit allowances, implements actions in collaboration with the physician reviewer panel, and monitors timeliness, decision-making, and processing of appeals, EMRs, and State Fair Hearings in accordance with regulatory and accrediting standardsB. Performs all necessary communication and documentation functionsCommunicates with internal staff, Members/LARs, physicians, hospital representatives, and otherProviders regarding case status, due process, rationale, and regulatory requirementsCoordinates Fair Hearing requests through TIERS when a Member/LAR or Provider requests an EMR or Fair HearingUtilizes an Independent Review Organization as needed for specialty or external reviewsOversees documentation and recordkeeping of all case communications in compliance with accrediting requirementsDocuments all activities and interactions in electronic and event tracking systemsGenerates appeal determination letters as appropriateC. Collaborates with clinical reviewers, medical directors, external physician reviewers, and network ProvidersCommunicates with physicians on each case to establish the most appropriate course of actionProvides education to nurse and therapist reviewers regarding appeal updates and process changesMaintains flexibility in scheduling, including evenings and weekends, to address pharmacy-related denialsEducates physician reviewers and clinical review staff on managed care and Medicaid policies and proceduresD. Conducts staff and medical director audits on appeal activitiesAssists with appeal file preparation for NCQA file reviewsSupports the development of corrective action plans based on trended audit findingsE. Provides data for internal and external reportingAnalyzes quarterly trends in appeal types and sourcesReports appeal activity, type, and resolution, ensuring timely communication standards are metAssists with state reporting in the required format and ensures timely submission to HHSC to avoid financial penaltiesKnowledge and SkillsDemonstrates proficiency in applying advanced principles, concepts, and techniques central to nursing and ancillary therapy services within managed care, with emphasis on complex pediatrics and obstetricsAbility to comprehensively assess Member and family medical needs, develop and implement plans of care, provide ongoing evaluation and monitoring, and deliver education to Members, families, Providers, and staffExemplary verbal and written communication skills, with proficiency in computer operation, word processing programs, fax machines, photocopiers, and multi-line telephonesStrong customer service orientation and advanced interpersonal communication skills with all levels of internal and external stakeholders, including medical staff, patients and families, clinical personnel, support staff, outside agencies, and community partnersQualificationsRN license in an eNLC (Enhanced Nurse Licensure Compact) state with multistate privileges3+ years Nursing experience1+ years’ Utilization Management experienceFamiliarity with medical terminology, utilization management guidelines, and clinical documentation standardsProficiency in Microsoft Office and experience working with healthcare systems or electronic medical recordsStrong organizational and time management skills with the ability to work independentlyExcellent written and verbal communication skillsAt BroadPath, a Sagility Company, we believe that transparency, authenticity, and collaboration are the keys to building strong, connected remote teams. If you are someone who values open communication, connection, and teamwork, you will thrive in our environment where showing up authentically matters.Benefits:Medical, Dental, and Vision coverage.Life Insurance.Short-Term and Long-Term Disability options.Flexible Spending Account (FSA).Employee Assistance Program.401(k) with employer contribution.Paid Time Off (PTO).Tuition Reimbursement.BroadPath, a Sagility Company, may conduct background checks, previous employment verifications, and education verifications, based on position requirementsDiversity StatementAt BroadPath, a Sagility Company, diversity is our strength. We embrace individuals from all backgrounds, experiences, and perspectives. We foster an inclusive environment where everyone feels valued and empowered. Join us and be part of a team that celebrates diversity and drives innovation!Equal Employment Opportunity/Disability/Veterans If you need accommodation due to a disability, please email us at HR@Broad-path.com. This information will be held in confidence and used only to determine an appropriate accommodation for the application process BroadPath, a Sagility Company is an Equal Opportunity Employer. We do not discriminate against our applicants because of race, color, religion, sex (including gender identity, sexual orientation, and pregnancy), national origin, age, disability, veteran status, genetic information, or any other status protected by applicable law. Compensation: BroadPath a Sagility Company has an effective process for assessing market data and establishing ranges to ensure we remain competitive. You are paid within the salary range based on your experience and market data of the position. The actual salary for this role may vary by location. Location:Work@Home USAUnited States of AmericaOriginally posted on Himalayas