LPN Clinical Appeals Specialist

2 weeks ago

Birmingham, Alabama, United States VIVA Health Full time
LPN, Appeals Clinical Coordinator

At VIVA Health, we are seeking a highly skilled LPN to join our team as an Appeals Clinical Coordinator. In this role, you will be responsible for analyzing and resolving appeals received from members, providers, and government entities.

Key Responsibilities:
  • Conduct clinical review and evaluation of Medicare member appeals, including non-participating provider appeals and participating provider appeals, using considerable clinical judgment, independent analysis, and detailed knowledge of medical policies, clinical guidelines, coverage criteria, and member benefit plans to determine the appropriateness of care.
  • Summarize cases including articulation of the provider or member's perception, initial denial determination and notification, analysis of medical records, and application of all applicable policies, guidelines, benefit plans, laws, and rules & regulations.
  • Identify system or individual care issues that resulted in failure to provide appropriate care to members or meet service expectations.
  • Work with department management to address these issues.
  • Process appeals according to federal and state regulations and internal, organizational policies and procedures.
Requirements:
  • High School Diploma or GED
  • 5 years' experience in a clinical or healthcare setting
  • Current LPN License in good standing with the State of Alabama Board of Nursing
  • Experience working with the elderly and disabled population and/or Medicaid Managed Care
  • Excellent written and verbal communication skills, interpersonal skills, organization skills, and the ability to handle multiple tasks
  • Ability to meet established productivity, schedule adherence, and quality standards
  • Ability to use critical thinking skills to develop solutions to clinical and non-clinical issues using fact-based decision-making
  • Proficient in the Microsoft Office suite of products with a strong proficiency in Microsoft Excel and Word
  • Ability to work occasional planned and unplanned overtime to meet deadlines with minimal supervision
  • Proficient in using standardized clinical guidelines as well as utilization management tools, including Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), Interqual, and Milliman guidelines
  • Ability to effectively analyze, interpret, apply, and communicate policies, procedures, and regulations
  • Ability to interact with all departments within the Company, outside vendors, and government regulatory agencies, including MDs and MD office staffs
Preferred Qualifications:
  • 3 years' experience in Medicare Managed Care
  • 1 year experience processing appeals or in utilization management or quality management
  • Knowledge of Medicare and commercial regulations of the Medicare Managed Care Manual
  • Knowledge of CPT/HCPC and ICD10 coding, procedures, and guidelines
  • Knowledge of the CMS and Palmetto websites

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