Job Description

• • Reviewing case details, payer policy, medical necessity rationale, and claim/authorization data
  • Determining the most appropriate next steps

• • Gathering required evidence (authorization history, eligibility/benefits support, clinical documentation/records and relevant claim details)
  • Ensuring submissions are organized and meeting payer requirements

• • Validate successful receipt/acceptance
  • Rapidly correct/resubmit when submissions are rejected or incomplete

• • Tracking due dates, statuses, required follow-ups and outcomes
  • Preventing missed appeal windows
  • Ensuring timely outcomes

• • Clarifying documentation needs
  • Coordinate next actions
  • Provide clear status updates throughout the appeal lifecycle

• • Ensuring complete traceability for internal review and write-off governance when applicable

• • Pushing for payer clarification/supervisor review when appropriate
  • Routing patterns of denials to the correct internal owners

• • Helping to drive scheduling within required timeframes
  • Capturing payer rationale from P2P interactions
  • Preparing appeal documentation in parallel to avoid delays if P2P is upheld

• • Producing insights that support continuous improvement and denial prevention

• • Updating templates/checklists
  • Supporting training enablement
  • Helping implement improved tracking/automation practices that strengthen compliance and reimbursement performance

• Minimum 3 years’ experience in a revenue cycle role managing authorizations and appeals
• Commercial insurance and Medicaid payor experience
• Experience with Texas Medicaid and MCOs preferred
• Competency with private duty nursing and homecare services
• Bachelor's degree preferred
• Ability to evaluate authorization denials, complete appeal packets, and manage complexity with payor protocol and procedure
• Ability to work independently and be detail-oriented ensuring full management of the process
• Strong communication and analytical skills
• Strong Excel skills

• A supportive and collaborative work environment.
• Opportunities for professional growth and development.
• Comprehensive benefits package, including health, dental, and vision insurance.
• A chance to make a meaningful impact in the lives of children and families.