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

Alignment Health • Remote CA Outside Bay Area, CA

13d • $77,905 - $116,858 • Remote

About The Position

Alignment Health is seeking a Clinical Appeals Nurse to review requests for appeals of both inpatient and outpatient services for all plan members. This role collaborates closely with providers, Regional and Senior Medical Directors, and Utilization Management to ensure timely processing of appeals, aiming for the highest quality medical outcomes in the most cost-efficient manner. Alignment Health is committed to serving seniors and the chronically ill, offering an opportunity to make a significant impact in a fast-growing company.

Requirements

• Minimum (2) years' clinical nursing experience (med / surg, case management, or acute care).
• Minimum 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 system (Access Express / Portal / N-coder).
• Knowledgeable with CMS (Chapter 13) guidelines and regulations.
• Computer Skills: Word, Excel, Microsoft Outlook.
• Proficiency with Clinical Case Management systems or EHR platforms.
• Effective written and oral communication skills; able to establish and maintain a constructive relationship with diverse members, management, employees, clinicians and vendors.
• Able to perform mathematical calculations and calculate simple statistics correctly.
• Able to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Able 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).
• Associates or Bachelor's degree in Nursing.
• Medical Terminology.
• Six Sigma.
• Bilingual English / Spanish.
• Transplant knowledge a plus.
• CPHQ or ABQAURP, or Six Sigma certification preferred.
• Medical Terminology Certificate.

Responsibilities

• Reviews and prepares appeal requests for medical necessity and refers to Medical Director any appeal that requires MD approval or denial.
• Independently applies evidence-based clinical criteria (Milliman, InterQual, CMS NCD / LCD) to conduct objective medical necessity reviews and make appeal determination recommendations.
• Maintain goals for established turn-around time (TAT) for appeal processing, in addition to managing expedited requests to ensure compliance with each appeal assigned.
• Coordinate peer-to-peer conversations to maintain professional rapport with providers, physicians, support staff and additionally patients to efficiently process appeals.
• Verify eligibility and / or benefit coverage for requested services when evaluating appeals.
• Verify accuracy of ICD 10 and CPT coding in processing appeal requests.
• Contact requesting provider and request medical records, orders, and / or necessary documentation to process an appeal when necessary.
• Review appeal denials for appropriate guidelines and language and prepares denial letters as appropriate.
• Contact members and maintain documentation of call and case notes in the system to ensure a complete and auditable record of every appeal decision.
• May 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 aligned with Alignment’s serving-heart culture.
• Other duties, tasks and projects be assigned as needed.

Benefits

• Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED