About New Leaf
Why Choose Us?
Staffing Solutions
For Employers
For Job Candidates
Employee Resources
Contact Us
Job Categories
Access Specialists
Administrative Support
Allied Health
Executive Search
Finance & Accounting
Healthplan Services
HIM Solutions
IT Solutions
Patient Financial Services
Physician/Medical Group Services


Apply Now!

LVN Appeals Specialist  

Summary: Manages submission, intervention and resolution of appeals, grievances, and/or complaints from members and related outside agencies as a part of the integrated Healthcare Services Team. Conducts pertinent research, evaluates, responds and completes appeals and other inquiries accurately, timely and in accordance with all established regulatory guidelines. Prepares appeal summaries and correspondence and documents information for tracking/trending data.

Essential Functions: Enters denials and requests for appeal into information system and prepares documentation for further review. Researches issues utilizing systems and clinical assessment skills, knowledge and approved Decision Support Tools in the decision making process regarding health care services and care provided to members. Assure timeliness and appropriateness of all Provider appeals according to state and federal guidelines. Request and obtain medical records, notes, and/or detailed bills as appropriate to assist with research. Evaluates for medical necessity and appropriate levels of care and formulates conclusions per protocol. Collaborates with Medical Directors and other team members to determine appropriate responses. Obtains Medical Director approval for determination per protocol. Work with Customer Service to resolve balance bill issues and other member complaints regarding providers. Prepare responses to provider grievances / appeals. Elevates appeals to the appropriate committee and/or manager per protocol. Prepares and assists in the preparation of the narratives, graphs, flowcharts, etc. to be utilized for presentations and audits. Coordinates workflow between departments and interface with internal and external resources. Receive and resolve provider inquiries related to claims. Act as a liaison between the providers and health plan as appropriate. Assist with interdepartmental issues to help coordinate problem solving in an efficient and timely manner. Identifies and refers cases appropriately for Health Management, Case Management, Quality Improvement and Health Education per established triggers.

Knowledge/Skills/Abilities: Comprehensive knowledge of health care customer service, regulatory requirements and Provider Dispute and/or Member Appeal process. Knowledge of CPT/HCPC and ICD9 coding, procedures and guidelines. Comprehensive clinical decision logic and analysis skills. Excellent vocabulary, grammar, spelling, punctuation, and composition skills proven through the development of written communication. Maintain regular attendance based on agreed-upon schedule Computer skills and experience with Microsoft Office Products. Excellent verbal and written communication skills Required Education: Completion of an accredited LVN or LPN Nursing program. Required Experience: 2 years of Utilization Review experience and Managed Care experience. Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of NCQA guidelines for appeals and denials Required Licensure/Certification: Active, unrestricted State Licensed Vocational Nurse or Licensed Practical Nurse in good standing.


19 - 20 /hr 


This exciting opportunity is available for hire immediately!!!!

Contact Email: resumes@newleafstaff.com
Phone: (800) 758-1427
Company: New Leaf Staffing
Job Status:  Full Time, Employee



| Home |Careers | Employer Login | Submit Resume | Apply Now |Refer a Friend | Contact Us |

Site Design by Netdancer Design Group