Appeals Nurse (LPN)
Iselin, NJ (Greater NYC area, near Staten Island)
Appeals Nurse Job Summary:
** This is a Full Time, Benefits Available, CONTRACT opportunity, expected to last 3-4 months, or longer! **
Appeals Nurse Background:
- Responsible for supporting the development and implementation of quality improvement interventions and audits.
- Researches, collects data, and submits and resolves administrative appeals.
- Contributes to external reviews site visit preparations by the State, accreditation review and Quality Management Committee
- Conducts internal monitoring and audits timeline compliance standards.
- Processes, tracks, trends, and reports complaint and grievances issues.
- Prepares complaint and grievance files for Fair Hearings and serves as a subject matter expert on complaints and grievances for non-clinical staff.
- Participates in quarterly Plan HIPAA audits.
- Current, valid, and unrestricted state Licensed Practical Nurse (L.P..N.) license.
- Around of 2 years acute care clinical nursing experience
- Minimum of 1-year previous experience in Denials/Appeals/Grievances for a Managed Care Organization.
- Minimum of 1-2 years of recent experience at a health plan or other Managed Care Organization (HMO/TPA/IPA/etc).
- Requires at least 1year of customer service experience communicating directly with members to identify their true complaint and obtain any additional information to resolve their case.
- Must be able to differentiate between PCP rendered care and specialty care; and be able to identify clinical quality of care issues.
- Understand Utilization Review guidelines, Medicare and Medicaid regulations, and appropriate state plan requirements.