Appeals and Grievances LVN

CommonSpirit Health•Rancho Cordova, CA

7d•Hybrid

About The Position

The Appeals and Grievances LVN is a critical role responsible for managing and resolving all medical necessity appeal requests from various stakeholders, including third-party payers, patients, and government entities. This individual acts as a primary liaison for clinical denials, navigating appeal processes through all delegated levels. Key responsibilities include intake, prioritization, and thorough review of appealed cases, ensuring all relevant documentation is presented to the Medical Director. The nurse must meticulously track and document all appeal activities, guaranteeing timely resolution in compliance with federal, state, and local regulations, including CMS guidelines. This role involves identifying necessary documentation for investigations, preparing files for regulatory appeals, and maintaining a detailed activity log for leadership review. The nurse will actively participate in audits, identifying and implementing process improvements to enhance efficiency and mitigate revenue loss due to denials. Staying current with plan policies and maintaining patient confidentiality (HIPAA) are also essential. Ultimately, the Appeals and Grievances Nurse monitors denial trends, recommends corrective actions, and provides regular reports to management and regulatory bodies, contributing to improved clinical quality and financial outcomes. Please note: This position is hybrid in-office/clinic and work from home.

Requirements

2+ years administrative experience in a compliance auditing arena. Previous experience in a similar administrative or coordination role.
Associates degree, or 3 years of industry or job related experience, in lieu of a degree.
Clear and current CA Licensed Vocational Nurse (LVN) license.
Familiarity with healthcare regulations, including HIPAA, CMS, and state-specific requirements

Nice To Haves

Bachelors degree, or 5 years of industry or job related expereince, in lieu of degree, preferred.
Certified Compliance Professional (CCP), Certified Professional in Healthcare Quality (CPQH), Certified Healthcare Auditor (CHA) preferred.
2 years managed care experience preferred.
1 year delegation oversight experience preferred.
Regulatory audit experience preferred.
Knowledge of DMHC, NCQA, CMS and other regulatory bodies preferred
Knowledge of HIPPA, managed care environment preferred
Strong technical proficiency in data analysis; database software preferred
Familiarity with compliance requirements is a plus

Responsibilities

managing and resolving all medical necessity appeal requests
acting as a primary liaison for clinical denials
navigating appeal processes through all delegated levels
intake, prioritization, and thorough review of appealed cases
ensuring all relevant documentation is presented to the Medical Director
meticulously track and document all appeal activities
guaranteeing timely resolution in compliance with federal, state, and local regulations, including CMS guidelines
identifying necessary documentation for investigations
preparing files for regulatory appeals
maintaining a detailed activity log for leadership review
actively participate in audits
identifying and implementing process improvements to enhance efficiency and mitigate revenue loss due to denials
Staying current with plan policies and maintaining patient confidentiality (HIPAA)
monitors denial trends
recommends corrective actions
provides regular reports to management and regulatory bodies
contributing to improved clinical quality and financial outcomes