Appeals LPN

Location: Iselin, NJ
Date Posted: 04-15-2019
Appeals Nurse (LPN)
Iselin, NJ (Greater NYC area, near Staten Island)

** This is a Full Time, Benefits Available, CONTRACT opportunity, expected to last 3-4 months, or longer! **

Appeals Nurse Job Summary:
  • 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.
Appeals Nurse Background:
  • 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.  
480.264.0620 (CALL – TEXT – FAX)
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