Clinical - Appeals Nurse - 210989

This team handles all Iowa Medicaid appeals except behavioral health Candidate Requirements Education/Certification Required: Associates Preferred: Licensure Required: LPN Preferred: RN Years of experience required: at least 2 years nursing experience, UM experience helpful. Position Purpose: Facilitate medical necessity appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met.

Job Summary
Position Purpose: Facilitate medical necessity appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met

Education/Experience: LPN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience. Proficient with Microsoft Office applications. Experience with utilization or appeals review preferred. Knowledge of InterQual criteria preferred.

License/Certification: RN or LPN license.

For Fidelis Care only: NYS RN license required.

Responsibilities
" Review clinical data to determine claim payment based on company policies and
" National Committee for Quality Assurance (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.

EEO:

Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.

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Job Summary Position Purpose: Facilitate medical necessity appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met Education/Experience: LPN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience. Proficient with Microsoft Office applications. Experience with utilization or appeals review preferred. Knowledge of InterQual criteria preferred. License/Certification: RN or LPN license. For Fidelis Care only: NYS RN license required. Responsibilities " Review clinical data to determine claim payment based on company policies and " National Committee for Quality Assurance (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.
Story Behind the Need
What is the purpose of this team? What is driving this need? (ex. Backfill for FTE or CW, new project, business growth) Describe the surrounding team (team culture, work environment, etc.) & key projects. Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?		Review and process Iowa Medicaid Member Appeals Volume of appeals continues to increase and is at an all-time putting team at risk for liquidated damages if cases are not 100% resolved in 30 days. The team is fully remote and highly experienced. They collaborate effectively, demonstrate strong accountability, and consistently work well together to manage complex appeals. Not currently
Typical Day in the Role
Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD). What are performance expectations/metrics? What makes this role unique?			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. This team handles all Iowa Medicaid appeals except behavioral health
Candidate Requirements
Education/Certification	Required: Associates				Preferred:
Licensure	Required: LPN				Preferred: RN
Years of experience required: at least 2 years nursing experience, UM experience helpful Disqualifiers: none Additional qualities to look for: The ideal candidate will thrive in a fast paced environment with frequently changing workloads. This role requires strong prioritization, organization, and adaptability.
Top 3 must-have hard skills stack-ranked by importance			1	Customer service
			2	Time management
			3	Computer skills/ability to learn new systems
Candidate Review & Selection
Shortlisting process Candidate review & selection Interview information Onboard process and expectations			Projected Manager Candidate Review Date:			1-2 days post shortlisting
			Type of Interviews:			Teams, 1 interview w/ HM and their supervisor
			Required Testing or Assessment (by Vendor):			N/A