Appeals Nurse - LPN

Job Title: Appeals Nurse Duration: 10 months contract (Possibility to extend) Location: Remote, preferred Iowa Possible to work on-site (1080 Jordan Creek Pkwy, West Des Moines, IA 50266) Shift Type: Mon-Fri 8am-5pm CST – No OT Payrate: $27-28/hrResponsibilities: • Review clinical data to determine claim payment based on company policies and • National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review • Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received • Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions • Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution • Gather and prepare case information for Administrative Law Hearings • Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database • Assist the Medical Director with revising, updating, and/or creating new policies to satisfy NCQA and contractual requirements.Typical Day in the Role: • Member appeal requests are received and assigned by the team lead, the appeals nurse is responsible for working the appeal start to finish. • Outreach attempts are made to member/provider. • A clinical review is completed and case sent to specialty review/MD. • Appeals nurse will write determination letters and close the case. • 30 calendar days to complete standard cases and 3 business days to acknowledge receipt of the case.Requirements: • LPN • At least 2 years nursing experience, UM experience helpful