Appeals Nurse - LPN
IMCS Group, West Des Moines, IA, United States
Overview
Duration: 10 months contract (Possibility to extend)
Location: Remote, preferred Iowa. Possible to work on-site (1080 Jordan Creek Pkwy, West Des Moines, IA 50266)
Shift Type: Mon-Fri 8am-5pm CST – No OT
Responsibilities
Review clinical data to determine claim payment based on company policies and NCQA guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review
Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received
Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines; create system authorization events for overturned denial decisions
Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution
Gather and prepare case information for Administrative Law Hearings
Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database
Assist the Medical Director with revising, updating, and/or creating new policies to satisfy NCQA and contractual requirements
Typical Day in the Role
Member appeal requests are received and assigned by the team lead; the appeals nurse is responsible for working the appeal start to finish
Outreach attempts are made to member/provider
A clinical review is completed and case sent to specialty review/MD
Appeals nurse will write determination letters and close the case
30 calendar days to complete standard cases and 3 business days to acknowledge receipt of the case
Requirements
At least 2 years nursing experience; UM experience helpful
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Duration: 10 months contract (Possibility to extend)
Location: Remote, preferred Iowa. Possible to work on-site (1080 Jordan Creek Pkwy, West Des Moines, IA 50266)
Shift Type: Mon-Fri 8am-5pm CST – No OT
Responsibilities
Review clinical data to determine claim payment based on company policies and NCQA guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review
Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received
Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines; create system authorization events for overturned denial decisions
Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution
Gather and prepare case information for Administrative Law Hearings
Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database
Assist the Medical Director with revising, updating, and/or creating new policies to satisfy NCQA and contractual requirements
Typical Day in the Role
Member appeal requests are received and assigned by the team lead; the appeals nurse is responsible for working the appeal start to finish
Outreach attempts are made to member/provider
A clinical review is completed and case sent to specialty review/MD
Appeals nurse will write determination letters and close the case
30 calendar days to complete standard cases and 3 business days to acknowledge receipt of the case
Requirements
At least 2 years nursing experience; UM experience helpful
#J-18808-Ljbffr