Clinical Appeals Nurse

General Duties/Responsibilities:

1.      Reviews and prepares appeal requests for medical necessity and refers to Medical Director any appeal that requires MD approval or denial

2.      Independently applies evidence-based clinical criteria (Milliman, InterQual, CMS NCD/LCD) to conduct objective medical necessity reviews and make appeal determination recommendations

3.      Maintain goals for established turn-around time (TAT) for appeal processing, in addition to managing expedited requests to ensure compliance with each appeal assigned

4.      Coordinates peer to peer conversations to maintain professional rapport with providers, physicians, support staff and additionally patients to efficiently process appeals

5.      Verifies eligibility and/or benefit coverage for requested services when evaluating appeals

6.      Verifies accuracy of ICD 10 and CPT coding in processing appeal requests

7.      Contacts requesting provider and request medical records, orders, and/or necessary documentation to process an appeal when necessary

8.      Reviews appeal denials for appropriate guidelines and language and prepares denial letters as appropriate

9.      Contacts members and maintain documentation of call and case notes in the system to ensure a complete and auditable record of every appeal decision

1. May participate in regulatory audits

11.   Manages all member cases utilizing HIPAA-compliant handling, storage, and communication of member information

12.   Fosters a culture of caring connections, accountability, and service excellence aligned with Alignment’s serving-heart culture

13.   Other duties, tasks & projects be assigned as needed

Job Requirements:

• Required:   2+ years of clinical nursing experience (med/surg, case management, or acute care) AND 1+ year of utilization management or appeals/denials experience in a managed care or health plan environment

• Preferred: 2+ years’ experience in a medical setting working with IPAs, entering referrals/prior authorizations. Experience with the application of clinical criteria (i.e., Milliman, InterQual, Apollo, 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 Sigma

Specialized Skills:

• Required:

·        Knowledge of ICD-10, CPT codes, Managed Care Plans, medical terminology and referral system (Access Express/Portal/N-coder)

·        Knowledgeable with CMS (Chapter 13) guidelines and regulations

·        Computer Skills: Word, Excel, Microsoft Outlook

·        Proficiency with Clinical Case Management systems or EHR platforms.

·        Language Skills: Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees, clinicians and vendors

·        Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly

·        Reasoning Skills: Ability 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

·        Ability to interpret and analyze complex medical records, physician notes, operative reports, imaging reports, and lab results

• Preferred: Bilingual (English/Spanish) preferred. Transplant knowledge a plus

Licensure:

• Required: Current, Active and Unrestricted California LVN or RN license

• Preferred: CPHQ or ABQAURP, or Six Sigma certification preferred. Medical Terminology Certificate