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Appeals LPN

Hanover, MD · Healthcare
Appeals LPN - Health Plan
Hanover, MD (near Baltimore BWI Airport)
*** This is a Full-Time, Benefits Available, CONTRACT opportunity, expected to last 4 months, or longer! ***

Appeals Nurse Job Summary: 
  • Conducts investigations and reviews of member and provider medical necessity appeals.
  • Reviews prospective, concurrent, or retrospective medical records of denied services for medical necessity.
  • Extrapolates and summarizes medical information for Medical Director and other external review.
  • Prepares recommendations on each appeal and forwards to Medical Director for approval.
  • Ensures that appeals and grievances resolutions meet regulatory time-frames.
  • Documents and logs appeal/grievance information.
  • Generates written correspondence to providers, members, and regulatory entities.
  • Serves as a subject matter expert for appeals/grievances/quality of care issues.

Appeals Nurse Background: 
  • Current, valid, and unrestricted state Licensed Practical Nurse (L.P.N.) license.
  • Around 2 years acute care clinical nursing experience
  • Minimum of 1-2 years of previous experience in Denials / Grievances / Appeals in a Managed Care Organization; may consider advanced Utilization Review experience as well.
  • Experience using standardized clinical guidelines (InterQual or Milliman/MCG) is required. 
  • Understand Utilization Review guidelines, Medicare and Medicaid regulations, and appropriate state plan requirements. 
  • Basic computer skills to include Microsoft Word, Excel, database use, and basic data entry.
  • Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts.

480.478.1635 (CALL – TEXT – FAX)
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