- Conduct and investigate member and provider medical necessity appeals
- Review prospective, inpatient, and retrospective medical records of denied services for medical necessity
- Ensures appeals and grievances are resolved in a timely manner
- Prepare clinical reviews and provides monitoring of cases involving medical decisions and quality of services and care
- Generate written correspondence to providers and members to achieve maximum overturn rate
- Provide input into corrective action plans for clinical and service events to improve decision-making or quality of care and services for internal and provider partner decisions
- Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received
- Presents recommendations based on clinical review, criteria, and organizational policies
- Complies with HIPAA and other compliance requirements to protect patient confidentiality
- Contact and educate patients and guarantors regarding necessary steps to resolve an outstanding insurance balance while providing exemplary customer service
- 2+ years of experience in a managed care healthcare setting
- 2+ years of Utilization Management
- Experience with payer specific medical guidelines and how to apply them in an appeal
- Experience using MCG and/or InterQual guidelines
- Current active California LVN license required
- Current active California RN license preferred
-
Nurse Appeals-CA
1 week ago
Elevance Health Costa Mesa, United StatesNurse Appeals- California candidates only · Location: This is a virtual position and prefer candidates reside within 50 miles of an Elevance Health PulsePoint location. · Schedule: Monday - Friday 8:00 am to 4:30 pm PST Saturdays and Holidays required · How you will make an impac ...
-
LVN Appeals Nurse
1 week ago
HealthCare Support Orange, United StatesAppeals Nurse · HealthCare Support is actively seeking an Appeals Nurse to fill an opening with a health insurance plan in Orange, California. This is an in office position. · Daily Responsibilities for Appeals Nurse: Participates in a mission-driven culture of high-quality per ...
-
Grievance and Appeals Nurse
1 week ago
The Midtown Group Orange, United StatesJob Summary · The Grievance and Appeals Nurse Specialist participates in managing medical appeals and state hearing reviews for all lines of business, including handling expedited and standard requests. The incumbent will ensure appeals and state hearing requests are processed i ...
-
Grievance and Appeals Nurse Specialist
1 week ago
Impresiv Health Orange, United StatesTitle: Grievance and Appeals Nurse Specialist · Duration: up to 6 months · Compensation: $40.87-$67.82 · **In Office** · Description: · The Grievance and Appeals Nurse Specialist participates in managing medical appeals and state hearing reviews for all lines of business, in ...
-
Grievance and Appeals Nurse Specialist
1 week ago
Impresiv Health Orange, United StatesTitle: Grievance and Appeals Nurse Specialist · Duration: up to 6 months · Compensation: $40.87-$67.82 · **In Office** · Description: · The Grievance and Appeals Nurse Specialist participates in managing medical appeals and state hearing reviews for all lines of business, in ...
-
TEMP - Grievance & Appeals Nurse Specialist
1 week ago
Cogent Infotech Corp Orange, United StatesJob Description : · The client is seeking a highly motivated an experienced TEMP - Grievance & Appeals Nurse Specialist to join the team. The Grievance and Appeals Nurse Specialist participates in managing the client's medical appeals and state hearing reviews for all lines of b ...
-
Grievance and Appeals Nurse
2 weeks ago
Sumeru Inc Orange, United States**Client: CalOptima Health** · **Job Title: Grievance and Appeals Nurse Specialist** · **Duration: 06 Months** · **Start Date: ASAP** · **Location: 505 City Parkway West, CA** · **Position Type: Contract** · **Interview Type: In Person/Web Interview** · **Ceipal ID: CAL_GANS07_BT ...
-
TEMP - Grievance & Appeals Nurse Specialist
1 week ago
Equiliem Orange, United StatesHealth is the single largest health plan in Orange County, serving one in four residents. Our motto — "Better. Together." — is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and profession ...
-
TEMP - Grievance & Appeals Nurse Specialist
1 week ago
Equiliem Orange, United StatesHealth is the single largest health plan in Orange County, serving one in four residents. Our motto "Better. Together. is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals w ...
-
TEMP - Grievance & Appeals Nurse Specialist
2 weeks ago
Equiliem Orange, United StatesHealth is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and profession ...
-
Nursing specialist as residential area manager
3 weeks ago
Apex Innovations Silverado, United StatesDo you love being able to help people in your nursing profession and value the joy of work? · ▸ If respectful interaction in the workplace is important to you · ▸ If you are looking for a strong team and a good working atmosphere · ▸ If appreciation and recognition motivate you · ...
-
Nurse / Caregiver (m/f/d) for Elderly Care
3 weeks ago
Stellar Enterprises Fairview, United StatesAre you passionate about helping people in your nursing profession and value joy in your work? · ▸ If respectful interaction in the workplace is important to you, · ▸ if you are looking for a strong team and a positive work environment, · ▸ if appreciation and recognition motivat ...
-
Nursing specialist as residential area manager
3 weeks ago
Omega Innovations Garden Grove, United StatesAre you passionate about helping people in your nursing profession and value joy in your work? · ▸ If respectful interaction in the workplace is important to you · ▸ If you are looking for a strong team and a good working atmosphere · ▸ If appreciation and recognition motivate yo ...
-
Nursing Service Management
3 weeks ago
Horizon Dynamics Dana, United StatesAre you a dedicated nursing manager and want to help people in your nursing profession? · ▸ If respectful interaction and a harmonious working atmosphere are important to you · ▸ If you are looking for a strong team that wants to achieve great things together · ▸ If appreciatio ...
-
Spectrum Ventures Laguna, United StatesDo you love being able to help people in your nursing profession and value the joy of work? · ▸ If respectful interaction in the workplace is important to you, · ▸ if you are looking for a strong team and a good working atmosphere, · ▸ if appreciation and recognition motivate you ...
-
senior psychologist, correctional facility
3 weeks ago
California Correctional Health Care Services San Bernardino County, United StatesJob Description and Duties · Recruitment and Retention Bonus available for clinicians newly hired with California Correctional Health Care Services. · In a correctional setting, consults with medical, social work, rehabilitation, education, nursing, custody, and other personnel ...
-
Dietary Cook
4 days ago
PACS Inc Chino, United StatesTrellis Chino is a 59-bed short term skilled nursing facility and is conveniently located just off the 60 freeway and across Chino Valley Medical Center. Trellis Chino believes in patient-centered care, that is why our building design provides our patients with all private suites ...
-
Dietary Cook
1 week ago
PACS Inc Chino, United StatesTrellis Chino is a 59-bed short term skilled nursing facility and is conveniently located just off the 60 freeway and across Chino Valley Medical Center. Trellis Chino believes in patient-centered care, that is why our building design provides our patients with all private suites ...
-
Case Manager
1 week ago
Kaiser Permanente Riverside Medical Center - KP Riverside, United StatesWeekly Pay Range - $2625 To $2917 · Summary: · Case Manager provide individuals, families, and groups with the psychosocial support needed to cope with chronic, acute, or terminal illnesses. Services include advising family caregivers. · Provide patients with information and c ...
-
Regional Home Care RN Consultant
6 days ago
Kaiser Walnut, United StatesJob Summary: · Provides/gathers clinical expertise for areas of compliance which involve medical necessity and/or quality concerns. Utilizes clinical expertise to conduct investigations and seek input from other clinical professionals as required. Acts as a liaison, problem-solv ...
Clinical Appeals Nurse - Corona, United States - KPC GLOBAL MEDICAL CENTERS INC.
Description
Job Description
Job DescriptionLVN RANGE $38.91-$55.62
RN RANGE $50-$85
Job Description:
Education/Experience Type:
AS/BS in Nursing
The posted pay scale represents the range the Company reasonably expects to pay candidates for this position. The actual wage for this position may depend on factors such as experience and education, specific skills and abilities, alignment with similar internal candidates, marketplace factors, an applicable collective bargaining agreement, and Company business practices.
Additional InformationLicense or Certification required for this job:
Yes
Vocational Nurse license
The Clinical Appeals Nurse is responsible for investigating and processing medical necessity appeals from members and providers to payers. Possesses the ability to conduct research on standards or practice, regulations, and policy relevant to any case. Responsible for overturning denied claims, upholding the denials and submitting cases to the Medical Director for review. Possesses the ability to communicate clearly and concisely, both verbally and in writing and utilize computer and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Ensures timely and accurate processing of all denials. Will ensure that denials are processed according to KPC Policies and meet all Health Plan, Federal and State requirements. Perform other duties as assigned.
