LVN Appeals Nurse

3 weeks ago

Orange, United States HealthCare Support Full time
Appeals Nurse
HealthCare Support is actively seeking an Appeals Nurse to fill an opening with a health insurance plan in Orange, California. This is an in office position.

Daily Responsibilities for Appeals Nurse:
  • Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
  • Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
  • Prepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions.
  • Ensures all cases are completed in accordance with state and federal regulatory requirements including timelines.
  • Resolves complex and sensitive member issues within established timelines.
  • Maintains departmental database and the integrity of records by accurately entering case actions to assigned cases.
  • Analyzes and reports cases through GARS' subcommittee.
  • Participates in departmental meetings, trainings and audits as requested.
  • Oversees state hearing cases.
  • Assists with the notification process to members or providers on the clinical decision issued.
  • Discusses appeal process, medical decisions and hearing rights with members.
  • Assists members in coordinating their services with providers and communicates the status and outcome to members.
  • Completes other projects and duties as assigned.
  • Shift: M-F any 8-hour shift between 7AM to 8PM PST
  • In office position reporting to Orange, CA 92868
Required Qualifications for Appeals Nurse:
  • Clear and active LVN license in CA
  • 5 years of experience as a nurse
  • 2+ years of Grievances and Appeals, Utilization Management (could be prior authorization, concurrent review, retrospective review), and/or Quality Management form a managed care setting
  • Knowledge of:
    • Medi-Cal and Medicare benefits/regulations
    • Clinical review processes including how to analyze and research clinical issues.
    • Appeals and grievance processes.
  • Ability to:
    • Analyze and complete written summaries on clinical cases.
    • Conduct research on standards of practice, regulations and policies and procedures that are relevant to review cases.
  • Computer Skills - Word, Outlook, Excel
  • Soft skills:
    • Problem solving skills
    • Organized
    • Time management skills
    • Strong written and verbal communication skills
Preferred Qualifications for Appeals Nurse:
  • Active Registered Nurse (RN) license to practice in the state of California.
  • Bilingual in English (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).

Benefits for Appeals Nurse:
• Immediate enrollment in Health Insurance
• Dental Insurance
• Life Insurance
• Employee Assistance Program (EAP)
• Access to Investment Accounts
• Career and educational tools within our Ingenovis ACT (Advocacy) Program

Pay: $40.87 - $67.82 an hour

Interested in being considered?
If you are interested in applying to this position, please click Apply Now for immediate consideration.
For additional consideration, please email a copy of your resume to dennis.lorence@healthcaresupport.com with your phone number, the job title and location, and our recruiters will reach out.

Healthcare Support Staffing, LLC is an equal employment opportunity employer and will consider all qualified applicants without regard to race, color, religion, disability, sex, sexual orientation, gender identity, national origin, protected veteran status, or any other characteristic protected by applicable local, state, or federal law.

#SlvLPN624 #mng

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