Appeals Nurse - LPN

IMCS Group; West Des Moines (IA); Hybrid; USD 60,000 - 80,000; Full time

Job summary

IMCS Group is seeking an experienced nurse for a 10-month contract role primarily focused on reviewing clinical data and managing member appeal requests in accordance with company policies. The position allows for remote work, preferably from Iowa, with possible on-site visits. Key responsibilities include preparing case reviews, generating appeal communications, maintaining the appeals process, and assisting with policy revisions. Candidates must have at least 2 years of nursing experience, with UM experience being beneficial.

Qualifications

• At least 2 years of nursing experience required; UM experience is helpful.

Responsibilities

• Review clinical data to determine claim payment based on policies.
• Prepare case reviews for the Medical Director.
• Generate appeal resolution communications in accordance with guidelines.
• Request additional information from providers to facilitate appeals.
• Gather and prepare case information for Administrative Law Hearings.
• Maintain appeals process within the prescribed timeframes.
• Assist the Medical Director with policy revisions to meet requirements.

Skills

Nursing experience

Understanding of UM

Job description

Overview

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

Responsibilities

• Review clinical data to determine claim payment based on company policies and 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

• At least 2 years nursing experience; UM experience helpful