Houston TX – Remote Appeals and Grievances RN

Job Overview

  • Clinical License RN
  • State(s) Compact, TX

The Appeals and Grievance Nurse is responsible for investigating and processing medical necessity and benefit coverage appeal and grievance requests from members and providers. This clinician reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. This associate independently coordinates the clinical resolution with internal and external partners as required, providing documentation and completing correspondence to applicable parties.

This associate is focused on the processing of customer and provider Medicare and Commercial appeals and grievances. This associate may screen incoming complaints, process medical necessity, utilization management and claims appeals, initiate Independent Review Organization external reviews as well as respond to CMS and department of insurance inquiries. The position will promote quality patient care and customer service/satisfaction, while promoting safety, cost efficiency and a commitment to the Continuous Quality Improvement Process.

This associate will interact on a daily basis with the Customer Service Department, Medical Management Department, Medical Directors, enrollees, providers and TPA Staff as may be necessary to effectively resolve appeals, complaints and quality of care or service issues

Reports to: Manager, Appeals and Grievances
Location: Houston, TX; will consider remote deployment


Essential Functions

    • Interact with internal departments, such as Customer Service, Medical Management, medical directors, Claims and Provider Relations, as well as members, providers and other external entities to effectively process appeals and claims in a timely and appropriate manner
    • Communicate decisions with appropriate, understandable correspondence




    • Licenses/Certifications: Current; unrestricted Texas (or Compact) licensure to practice as a Registered Nurse required
    • Three (3) years of experience in a clinical setting required
    • Previous experience in a managed care environment managing appeals and grievances preferred
    • Knowledge of ICD-9/CPT coding
    • Knowledgeable and compliant with all relevant laws, rules, regulations and accreditation standards and requirements, including but not limited to Texas Department of Insurance (TDI), CMS, National and Local Coverage Determinations, and Medicare Managed Care Manual
    • Knowledge of insurance terminology
    • Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint), and familiarity with Facets, EZCare/EZCap and/or Wipro preferred
    • Excellent verbal and written communication skills that includes member and provider correspondence (proper punctuation, correct spelling, understandable explanations)
    • Demonstrates critical thinking skills, ability to read and interpret medical records
    • Exceptional documentation skills
    • Ability to perform multiple tasks simultaneously, prioritize projects, work independently under pressure, and meets critical deadlines




Required: Associates or Bachelor’s degree in Nursing




  • Responsible for receiving, investigating, and responding both verbally and in writing to member and provider appeals and grievances (Medicare and commercial)
  • Reviews all supporting clinical and benefit information thoroughly and requests additional information as required.
  • Reviews medical records of denied services that have been submitted upon appeal for medical necessity and benefit coverage determination. Utilizes clinical criteria to make determinations and communicates with medical directors as appropriate.
  • Triages all standard and expedited appeals and grievances appropriately according to type and urgency complying with State and Federal regulatory requirements for timeliness.
  • Extrapolates and summarizes medical information for Chief Medical Officer, physician reviewer in the absence of the Chief Medical Officer, and external review organizations.
  • Prepares clinical reviews and provides monitoring of cases involving medical decisions and quality of care or service, and ensures all cases are completed in accordance with State and Federal regulatory requirements for timeliness.
  • Meets timeframes for performance with balancing the need to produce high quality work and resolving complex and sensitive member issues. Upon direction by the Chief Medical Officer forwards all cases which do NOT meet existing criteria, guidelines, and protocols to an Independent Reviewing Organization that has the appropriate physician specialty for final determination.
  • Demonstrates appropriate judgment skills to be able to make independent clinical decisions based upon existing criteria, guidelines and protocols
  • Acts as resource person for Medical Management/Utilization Review staff.
  • Assists as needed with benefit committee work as related to appeals and grievances.
  • Communicate, collaborate, and cooperate with internal and external stakeholders.
  • Adheres to all Compliance/Program Integrity and HIPAA regulations.
  • Identifies potential quality of care issues and notifies the quality improvement team.
  • Reports potential risk management cases or situations to the Manager of Appeals and Grievances and/or Medical Management leadership for immediate intervention or investigation.
    • Some travel in the Houston metro area may be required
    • Remote deployment will be considered



Technical Skills

    • Microsoft Office products
    • Facets, EZCap and/or Wipro experience preferred



About Apex Health Solutions

Apex Health Solutions powers payers and providers choosing to engage in value-based risk contracting. Apex’s unique solutions create alignment between payers and providers, generating unparalleled value. Combined with Apex’s experienced and successful industry leadership, our focal point remains on improvement in patient quality, satisfaction and overall cost of care.

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