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:
Appeals Nurse Background:
- 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.
- 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.