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. The Secondary Review and Notification RN utilizes critical thinking and experience to make certain that citations of regulatory requirements occur and that an accurate assessment of unmet needs has been documented. In addition, the Secondary Review and Notification RN is also responsible for completing the regulatory requirements for notification of determinations to members and/or providers. As a secondary reviewer you will be responsible for providing feedback, confirming the original decision, or raising concerns if needed. This position will work closely with the Utilization Management (UM) team, Service Coordination (SC) team and Medical Directors when required.


JOB SPECIFICATIONS

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/Specialized Training/Licensure: Current, unrestricted RN license in the state of Texas required.

BSN preferred.

Work Experience (Years and Area):
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/Medicare population experience required.

LTSS Utilization Management environment preferred.

Software Proficiencies: Microsoft Office (Word, Excel, and
Outlook).