- Full Time/Contract
- Appeals & Grievances
- Rancho Cucamonga, CA
Our Client is a not-for-profit, rapidly growing Medi-Cal and Medicare health plan serving over 1,138,447 residents of the Riverside and San Bernardino counties. Our client maintains a Positive Team Culture as demonstrated by being voted by Los Angeles News Group readers as "Favorite Overall Company to Work For, "Favorite Training Program, and "Favorite Workplace Culture in their 2014 Winning Workplaces survey.
Appeals Nurse LVN
Under the general direction of the Appeals Manager, the Appeals Nurse is responsible for working directly with the IPAs, Hospitals, internal Company departments, and the appeals team to ensure compliance of the Appeals Policy & Procedures and DMHC/Client/CMS regulations. Coordinate care of Members in conjunction with the Member’s PCP and IPA and or Company Team Members to provide continuous quality care and assist in the development of quality initiatives. The Appeals Nurse serves as a resource person to Company personnel, as well as, external practitioners and providers.
1. Work closely with the appeals team under the direction of the Appeals Manager with Member Services, Provider Services, Compliance, Medical Services Departments, and DMHC/Client/CMS to ensure all Member and Provider appeals are investigated, and care is coordinated appropriately.
2. Review Provider and Member appeals based on situations and make appropriate determination based on documentation presented by appealing agent with references to federal, state and local regulations as well as Company policy and procedures based on line of business in a timely manner.
3. Ensure compliance with state and federal guidelines, including Centers for Medicare and Medicaid Services requirements.
4. Prepares recommendations to either uphold or deny appeal using appropriate criteria hierarchy and forwards to Medical Director for approval.
5. Prepare files for Appeals Committee reviews.
6. Generates written correspondence to Providers, Members, and regulatory entities using appropriate grammar and punctuation.
7. Utilize leadership skills and serves as a subject matter expert for appeals and is a resource for clinical and non clinical team members in expediting the resolution of outstanding issues. Maintain all appeals documentation according to external agency requirements.
8. Under the direction of the Appeals Manager the Appeals Nurse shall assist with interpreting departmental policies, procedures, regulations, benefits (including evolving benefits), and other processes for Company Members. Responsible for serving as a resource for Company Member Services Department, Provider Services Department, and Medical Services Department for all appeals.
SKILLS & QUALIFICATIONS
COMPENSATION | POSITION CLASSIFICATION
- Full-Time | Contract Assignment