Clinical Appeals Nurse, California LVN/RN License

🕒 2 days ago

🏄 California – Remote

🏄 California – Remote

💵 $77.9k - $116.9k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

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Alignment Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2013

⚕️ Healthcare Insurance

🛡️ Insurance

🏥 Healthcare

💰 $135M Series C on 2020-03

Healthcare Insurance • Insurance • Healthcare

Alignment Health is dedicated to providing comprehensive care for Medicare members, emphasizing the needs of seniors, the chronically ill, and those who are frail. With a mission to transform senior healthcare, Alignment Health leverages a tailored care model and advanced technology to deliver high-quality, low-cost healthcare services. Their 24/7 concierge care team collaborates with trusted local providers to ensure that every member receives personalized care, reflecting the company's commitment to treating all members as valued family members.

📋 Description

• 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 for appeal processing, in addition to managing expedited requests • Coordinate peer-to-peer conversations to maintain professional rapport with providers, physicians, support staff and additionally patients • Verify eligibility and / or benefit coverage for requested services when evaluating appeals • Verify accuracy of ICD 10 and CPT coding in processing appeal requests • 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

🎯 Requirements

• 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 • 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 • Bilingual English / Spanish preferred.

🏖️ Benefits

• Health insurance • Paid time off • Professional development opportunities