Utilization Management Appeals Nurse (Hybrid - Indianapolis, IN)

CNSI and Kepro are now Acentra Health! Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact.

Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company, to actively engage in problem-solving, and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes – making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.

Acentra is currently looking for a Utilization Management Appeals Nurse – LPN/RN to join our growing team.

Job Summary:

Our Utilization Management Appeals Nurse – LPN/RN will help orchestrate the seamless resolution of appeals in line with health regulations. He or She will collaborate with internal teams, medical practitioners, and regulatory bodies to ensure timely and complaint processing. They will be a crucial resource for the Appeals Team, contribute to quality initiatives, and champion continuous care for our members. From meticulous case reviews to serving as a subject matter expert, the Appeals Nurse will play a vital role in upholding Acentra Health’s commitment to excellence and innovation in healthcare.

Hours:

** Generally, Monday to Friday between the hours of 8:00 AM to 5:00 PM Eastern. **

** Some weekends and holidays may be needed. **

** The exact schedule will be discussed during the interview. **

Travel:

** Must reside within a commutable distance of Indianapolis, Indiana.

** Some travel, at company expense, to Indianapolis, Indiana, may be required to attend in-person hearings as needed. **

Job Responsibilities:

• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.
• Assists the team in fulfilling department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Prepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions.
• Ensures all cases are completed in accordance with state and federal regulatory requirements, including timelines.
• Presents recommendations based on clinical review, criteria, and organizational policies to physician reviewers for final determination.
• Resolves complex and sensitive member issues within established timelines.
• Maintains departmental database and the integrity of records by accurately entering case actions to assigned cases.
• Participates in departmental meetings, training, and audits as requested.
• Participates in state hearing cases.
• Assists with the notification process to members and providers on the clinical decision issued.
• Discusses appeal process, medical decisions, and hearing rights with members and providers.
• Assigns position statements and represents at state hearings.
• Completes other projects and duties as assigned.

Possesses the Ability To:

• Analyze and complete written summaries on clinical cases.
• Conduct research on standards of practice, regulations, policies, and procedures that are relevant to review cases.
• Communicate issues clearly and timely to members, providers, involved departments, or health networks.
• Organize and manage activities related to processing cases within the department.
• Establish and maintain effective working relationships with leadership and staff.
• Communicate clearly and concisely, both orally and in writing.
• Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word, and SharePoint) and job-specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment.

Required Qualifications/Experience:

• Active Registered Nurse (RN) or Licensed Practical Nurse (LPN) license to practice in the state of Indiana or a Compact license.
• Previous healthcare/managed care Appeals experience.
• 2+ years of healthcare/managed care experience, preferably in the following related areas of responsibility: Utilization Management and/or Quality Management.
• Experience with Medicaid program regulati