Clinical Appeals Nurse, California LVN/RN License
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Job Description
Clinical Appeals Nurse responsible for reviewing and preparing appeals for inpatient and outpatient services in California. Collaborating with providers and ensuring timely processing of appeals for plan members.
Responsibilities:
- Responsible for reviewing requests for appeals of both inpatient and outpatient services for all plan members
- Collaborates closely with providers, Regional and Senior Medical Directors and Utilization Management for timely processing of appeals
- Reviews and prepares appeal requests for medical necessity and refers to Medical Director any appeal that requires MD approval or denial
- Independently applies evidence-based clinical criteria to conduct objective medical necessity reviews and make appeal determination recommendations
- Maintain goals for established turn-around time (TAT) for appeal processing
- Coordinate peer-to-peer conversations to maintain professional rapport with providers and patients
- Verify eligibility and/or benefit coverage for requested services
- Verify accuracy of ICD 10 and CPT coding in processing appeal requests
- Review appeal denials for appropriate guidelines and language and prepare denial letters as appropriate
Requirements:
- Minimum (2) years' clinical nursing experience
- Minimum 1 year utilization management or appeals / denials experience in a managed care or health plan environment
- Completion of an accredited LVN or RN nursing program
- Knowledge of ICD-10, CPT codes, Managed Care Plans, medical terminology and referral system
- Proficiency with Clinical Case Management systems or EHR platforms
- Effective written and oral communication skills; able to establish and maintain a constructive relationship with diverse members, management, employees, clinicians and vendors
- Able to interpret and analyze complex medical records, physician notes, operative reports, imaging reports, and lab results
- Current, Active and Unrestricted California LVN or RN license
Benefits:
- Health insurance
- 401(k) matching
- Flexible work hours
- Paid time off
- Remote work options
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