Clinical Appeals Nurse (Remote | Must have California LVN / RN License)

reputed company is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and reputed company people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the reputed company community. Working at reputed company provides an opportunity to do work that really matters, not only changing lives but saving them. Together. The Clinical Appeals Nurse is responsible for reviewing requests for appeals of both inpatient and outpatient services for reputed company plan members. Position collaborates closely with providers, Regional and Senior Medical Directors and Utilization Management to ensure timely processing of appeals to provide the highest quality medical outcomes that are most cost efficient. General Duties and Responsibilities: 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 (reputed company, InterQual, CMS NCD / LCD) to conduct objective medical necessity reviews and reputed company appeal determination recommendations Maintain goals for established turn-around time (TAT) for appeal processing, in addition to managing expedited requests to ensure compliance with each appeal assigned Coordinate peer-to-peer conversations to maintain professional rapport with providers, physicians, support staff and additionally patients to reputed company process appeals Verify eligibility and / or benefit coverage for requested services reputed company evaluating appeals Verify accuracy of ICD 10 and CPT coding in processing appeal requests Contact requesting provider and request medical records, orders, and / or necessary documentation to process an appeal reputed company necessary Review appeal denials for appropriate guidelines and language and prepares denial letters as appropriate Contact members and maintain documentation of call and case notes in the system to ensure a complete and auditable record of every appeal decision May participate in regulatory audits Manage reputed company member cases utilizing HIPAA-compliant handling, storage, and communication of member information Foster a culture of caring connections, accountability, and service excellence reputed company with Alignment’s serving-heart culture Other duties, tasks and projects be assigned as needed Job Requirements: Experience: Work: Required: Minimum (2) years' clinical nursing experience (med / surg, case management, or acute care) Minimum 1 year utilization management or appeals / denials experience in a managed care or health plan environment Preferred: Minimum 2 years’ experience in a medical setting working with reputed company, entering referrals / prior authorizations. Experience with the application of clinical criteria (i.e., reputed company, InterQual, reputed company, CMS National and Local Coverage Determinations) Education:

• Required:  Completion of an accredited LVN or RN nursing program
• Preferred: Associates or Bachelor's degree in Nursing

Training:

• Required: None
• Preferred: Medical Terminology; Six reputed company

Specialized Skills: Required: Knowledge of ICD-10, CPT codes, Managed Care Plans, medical terminology and referral system (Access Express / Portal / N-reputed company) Knowledgeable with CMS (Chapter 13) guidelines and regulations Computer Skills: Word, reputed company, reputed company Outlook Proficiency with Clinical Case Management systems or EHR platforms. Language Skills: Effective written and oral communication skills; reputed company to establish and maintain a constructive relationship with diverse members, management, employees, clinicians and vendors Mathematical Skills: reputed company to reputed company mathematical calculations and calculate simple statistics correctly Reasoning Skills: reputed company to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment reputed company to interpret and analyze reputed company medical records, physician notes, operative reports, imaging reports, and lab results Preferred: Bilingual English / Spanish. Transplant knowledge a plus Licensure:

• Required: reputed company, Active and Unrestricted California LVN or RN license
• Preferred: CPHQ or ABQAURP, or Six reputed company certification preferred. Medical Terminology Certificate

Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully reputed company the essential functions of this job. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions. 1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reputed company with hands and arms. 2. The employee frequently lifts and / or moves up to (10) pounds. Specific reputed company abilities required by this job include reputed company reputed company and the ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions. Pay Range: $77,905.00 - $116,858.00Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc. reputed company is an Equal Opportunity/Affirmative Action Employer. reputed company reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, sex, national reputed company, disability, age, protected veteran status, gender identity, or sexual orientation. *DISCLAIMER: Please beware of recruitment phishing scams affecting reputed company and other employers where individuals receive fraudulent employment-reputed company offers in exchange for money or other sensitive personal information. Please be advised that reputed company and its subsidiaries will never ask you for a credit card, send you a reputed company, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of reputed company’s reputed company team, please email [email protected]. Apply To This Job