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

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Clinical Appeals Nurse is responsible for reviewing requests for appeals of both inpatient and outpatient services for all plan members. Position collaborates closely with providers, Regional and Senior Medical Directors and Utilization Management to ensure timely processing of appeals to provide the highest quality medical outcomes that are most cost efficient.

General Duties and 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

Job Requirements:

Experience:

Work:

Required:   

• 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

Preferred:

• 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)

Education:

• Required:  Completion of an accredited LVN or RN nursing program

• Preferred: Associates or Bachelor's degree in Nursing

Training:

• Required: None

• Preferred: Medical Terminology; Six Sigma

Specialized Skills:

Required:

• 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.

• Language Skills: Effective written and oral communication skills; able to establish and maintain a constructive relationship with diverse members, management, employees, clinicians and vendors

• Mathematical Skills: Able to perform mathematical calculations and calculate simple statistics correctly

• Reasoning Skills: 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

• Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced envir