LPN-Member Appeals - Birmingham, United States - VIVA Health

Description

Attention LPN's VIVA HEALTH, ranked one of the nation's Best Places to Work by Modern Healthcare, is seeking an LPN

• Member Appeals & Grievances Specialist to join our team in Birmingham, ALThe ideal candidate will have strong clinical and analytical skills and also willing to do non clinical work in addressing appeals and grievances of all types.

The LPN

• Member Appeals & Grievances Specialist analyzes and resolves Medicare appeals and grievances received from members, non contracted providers, and government entities.

This position will also perform advanced clinical case review by evaluating the appropriateness of medical care and services provided to members requiring considerable clinical judgment, independent analysis, and detailed knowledge of managed health care, departmental procedures, clinical guidelines, and VIVA HEALTH policies.

This LPN will also participate in an on-call rotation for appeals that must be responded to on weekends and holidays.

This position will also assist with commercial complaints and provider appeals as needed.
VIVA HEALTH is the first and only Alabama-based plan to be named an overall 5-out-of-5 Star Medicare Advantage Plan. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys. We also offer a great benefits package, including tuition reimbursement for employees and dependents, 401(k), paid parental leave, and paid day for community service, just to name a few Come join our team


REQUIRED:
High School Diploma or GED1 year experience in a clinical, managed care, or healthcare settingCurrent LPN License in good standing with the State of Alabama Board of NursingLicensed Practical Nurse CertificationExcellent written and verbal communication skills, interpersonal skills, organization skills, and the ability to handle multiple tasksAbility to interact with all departments in the company, as well as medical directors, outside vendors and physician office staff, and government regulatory agenciesAbility to carefully follow processes in sequential orderProficient in using standardized clinical guidelines, as well as utilization management tools, including Medicare National Coverage Determinations and Local Coverage Determinations, lnterqual, and MillimanAbility to effectively analyze, interpret, apply, and communicate policies, procedures, and regulationsAbility to meet established productivity, schedule adherence, and quality standardsProficient in the Microsoft Office suite of products, with a strong proficiency in Microsoft Excel and WordAbility to work occasional planned and unplanned overtime to meet deadlines with minimal supervision


PREFERRED:
Associate or Bachelor's degree1 year of experience processing appealsExperience working with the elderly and disabled population and/or Medicaid Managed CareKnowledge of Medicare and commercial regulations, including Part C and D enrollee grievances, organization coverage determinations, and appeals guidanceKnowledge of CPT/HCPC and ICD10 coding, procedures, and guidelinesKnowledge of the CMS and Palmetto websitesClick Here to learn more about how VIVA HEALTH is building a culture where diverse voices, backgrounds, and perspectives are welcomed and celebrated