Clinical Appeals Nurse (Remote | Must have California LVN / RN License)

Alignment Health•Remote CA Outside Bay Area, CA

1d•$77,905 - $116,858•Remote

About The Position

Alignment Health is seeking a Clinical Appeals Nurse to join their mission-driven team focused on serving seniors and the chronically ill. This role involves reviewing requests for appeals of inpatient and outpatient services, collaborating with various stakeholders to ensure timely processing and optimal medical outcomes. The company emphasizes a culture of caring, accountability, and service excellence, offering opportunities for growth and innovation in a fast-growing organization dedicated to transforming senior care.

Requirements

Minimum of 2 years' clinical nursing experience (med/surg, case management, or acute care).
Minimum of 1 year utilization management or appeals/denials experience in a managed care or health plan environment.
Completion of an accredited LVN or RN nursing program.
Knowledge of ICD-10, CPT codes, Managed Care Plans, medical terminology, and referral systems (Access Express / Portal / N-coder).
Knowledgeable with CMS (Chapter 13) guidelines and regulations.
Proficiency with Microsoft Word, Excel, and Outlook.
Proficiency with Clinical Case Management systems or EHR platforms.
Effective written and oral communication skills.
Ability to establish and maintain constructive relationships with diverse members, management, employees, clinicians, and vendors.
Ability to perform mathematical calculations and calculate simple statistics correctly.
Ability to prioritize multiple tasks.
Advanced problem-solving skills.
Ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement, and manage appropriate resolutions.
Effective problem-solving, organizational, and time management skills.
Ability to work in a fast-paced environment.
Ability to interpret and analyze complex medical records, physician notes, operative reports, imaging reports, and lab results.
Current, Active, and Unrestricted California LVN or RN license.

Nice To Haves

Minimum 2 years' experience in a medical setting working with IPAs, entering referrals/prior authorizations.
Experience with the application of clinical criteria (i.e., Milliman, InterQual, Apollo, CMS National and Local Coverage Determinations).
Associate's or Bachelor's degree in Nursing.
Medical Terminology training.
Six Sigma training.
Bilingual English/Spanish.
Transplant knowledge.
CPHQ or ABQAURP, or Six Sigma certification.

Responsibilities

Review and prepare appeal requests for medical necessity, referring to Medical Director when MD approval or denial is required.
Apply evidence-based clinical criteria (Milliman, InterQual, CMS NCD / LCD) to conduct medical necessity reviews and recommend appeal determinations.
Maintain established turn-around times (TAT) for appeal processing, including managing expedited requests.
Coordinate peer-to-peer conversations with providers, physicians, support staff, and patients to process appeals.
Verify eligibility and/or benefit coverage for requested services.
Verify accuracy of ICD 10 and CPT coding in appeal processing.
Contact requesting providers to obtain necessary medical records, orders, and documentation.
Review appeal denials for appropriate guidelines and language, and prepare denial letters.
Contact members, document calls, and maintain case notes in the system for an auditable record.
Participate in regulatory audits.
Manage all member cases utilizing HIPAA-compliant handling, storage, and communication of member information.
Foster a culture of caring connections, accountability, and service excellence.
Perform other duties, tasks, and projects as assigned.