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Clinical Appeals Nurse (RN)

Lancesoft

  • Remote, CA
  • 3 days ago
  • Remote
  • $49

Highlights

Required Years of Experience: At least 2 years clinical nursing experience, including at least 1 year of utilization review (prospective, retrospective and concurrent clinical review), medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Client policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions.

Numbers & Facts

LocationRemote, CA (
Remote
)
IndustryStaffing/Employment Agencies
Salary$49
Company Size2,000 to 2,499 employees
Year Founded2000
Websitehttp://www.lancesoft.com/

Description

Job Tittle: Healthcare - Clinical Appeals Nurse (RN)
Location: Location: Remote –Must reside in **AZ, FL, GA, ID, IA, KY, MI, MS, NE, NM, NY (outside Greater NYC), OH, SC, TX, UT, WA (outside Greater Seattle), or WI.
Pay Range: $49.00 - $51.00
Duration: 3+ Months
Shift Timing: Mountain TIme- M-F 8am-5pm (can be flexible(ish) earlier start, as long as it fits in good times to reach provider groups as needed
 
Job Description:
  • Will this role be fully remote?: Yes
  • Are there any specific locations the candidates should be in (i.E., do they need to live in IL): No but must have CA license
  • Work Schedule/Shift & Time Zone: 7: 30am-4pm PST
  • Day to Day: Responsible for triaging and resolving member and provider clinical appeals and grievances.
  • Required Education/Certification(s): Clinical (LVN/RN) licensing in California. Compact licensing preferred.
  • Required Years of Experience: 1-2 years
  • Is there potential for this to extend past 3 months and/or convert to an FTE?: No
  • Facilitates medical review of prospective, retrospective, and concurrent review of appeals for denied prior authorizations. Includes standard and expedited cases, inpatient, outpatient, and pharmaceutical authorization appeals.
  • Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing.
  • Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Client policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions.
  • Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers.
  • Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues.
  • Identifies and reports quality of care issues.
  • Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team;makes decisions and recommendations pertinent to clinical experience.
  • Prepares and presents cases representing Client, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings.
  • Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions.
  • Supplies criteria supporting all recommendations for denial or modification of payment decisions.
  • Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals.
  • Provides training and support to clinical peers.
  • Identifies and refers members with special needs to the appropriate Client program per applicable policies/protocols.
  • Facilitates medical review of prospective, retrospective, and concurrent review of appeals for denied prior authorizations. Includes standard and expedited cases, inpatient, outpatient, and pharmaceutical authorization appeals.
  • Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing.
  • Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Client policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions.
  • Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers.
  • Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues.
  • Identifies and reports quality of care issues.
  • Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team;makes decisions and recommendations pertinent to clinical experience.
  • Prepares and presents cases representing Client, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings.
  • Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions.
  • Supplies criteria supporting all recommendations for denial or modification of payment decisions.
  • Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals.
  • Provides training and support to clinical peers.
  • Identifies and refers members with special needs to the appropriate Client program per applicable policies/protocols.
 
Must Have Skills:
  • Analytic, problem-solving, and decision-making skills.
  • Organizational and time-management skills.
  • Attention to detail.
  • Critical-thinking and active listening skills.
  • Common look proficiency.
  • Effective verbal and written communication skills.
  • Microsoft Office suite and applicable software program(s) proficiency.
  • Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and
  • Healthcare Common Procedure Coding (HCPC).
  • Experience working within applicable state, federal, and third-party regulations.
 
Required Years of Experience:
  • At least 2 years clinical nursing experience, including at least 1 year of utilization review (prospective, retrospective and concurrent clinical review), medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience.
 
Required Licensure / Education:
  • Registered Nurse (RN)/Licensed Practical Nurse (LPN) License must be active and unrestricted in state of practice. Compact license is acceptable where states allow.
 
Employee Benefits:
At LanceSoft, full-time regular employees who work a minimum of 30 hours a week or more are entitled to the following benefits:
•          Four options of medical Insurance
•          Dental and Vision Insurance
•          401k Contributions
•          Critical Illness Insurance
•          Voluntary Permanent Life Insurance
•          Accident Insurance
•          Other Employee Perks
LanceSoft is a certified Minority Business Enterprise (MBE) and an equal opportunity employer. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.
This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. LanceSoft makes hiring decisions based solely on qualifications, merit, and business needs at the time.
 
 
 

About Company

We are a $125 Million, NMSDC-certified Minority & Woman owned Workforce Solutions Company headquartered in the DC metro area with presence across US with global presence - Canada, Mexico, India, UK, Malaysia, Indonasia, Hongkong, Singapore, UAE. We are specialized in providing Workforce Solutions, SOW project delivery, Engineering Solutions, Creative Services. We currently support 100+ Fortune companies globally and across multiple industry segments. We are currently supporting several massive programs across industry segment nationally/globally (Intel, Ally, AMD, QUALCOMM, Morgan Stanley, Kraft/ Mondelez, MNP, Amdocs, Dell, SanDisk, Medtronic, Becton Dickinson, GE, Lockheed Martin, UTC, L-3 Communications, Caterpillar, BMW, Mercedes Benz, National Grid, Dominion, Energy Future Holdings, PSEG, 3M, Fidelity, Aetna, Humana, Johnson & Johnson, Pfizer, Merck etc). 

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender, identity, national origin, disability, or protected veteran status.

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