Experienced Utilization Management Appeals Nurse - LPN/RN (Hybrid Role) - Healthcare Appeals and Clinical Review Specialist

Introduction to Acentra Health

Acentra Health is a pioneering force in the healthcare industry, driven by a mission to empower better health outcomes through technology, services, and clinical expertise. Our company exists to innovate health solutions that deliver maximum value and impact, and we're committed to making a positive difference in the lives of our members. As a vital partner for health solutions in the public sector, we're dedicated to redefining expectations for the healthcare industry. At Acentra Health, we believe in the power of collaboration, innovation, and compassion, and we're looking for talented individuals to join our team and help us achieve our vision.

About the Role

We're currently seeking an experienced Utilization Management Appeals Nurse - LPN/RN to join our growing team. As a Utilization Management Appeals Nurse, you will play a vital role in orchestrating the seamless resolution of appeals in line with health regulations. You will collaborate with internal teams, medical practitioners, and regulatory bodies to ensure timely and compliant processing of appeals. This is a hybrid role that offers the flexibility to work remotely, with occasional travel to Indianapolis, Indiana, for in-person hearings.

Key Responsibilities

• Participate in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.
• Assist the team in fulfilling department responsibilities and collaborate with others to support the department's short- and long-term goals/priorities.
• Prepare clinical reviews based on clinical guidelines and provide monitoring of cases involving medical decisions and quality of care or service decisions.
• Ensure all cases are completed in accordance with state and federal regulatory requirements, including timelines.
• Present recommendations based on clinical review, criteria, and organizational policies to physician reviewers for final determination.
• Resolve complex and sensitive member issues within established timelines.
• Maintain departmental database and the integrity of records by accurately entering case actions to assigned cases.
• Participate in departmental meetings, training, and audits as requested.
• Participate in state hearing cases and assist with the notification process to members and providers on the clinical decision issued.
• Discuss appeal process, medical decisions, and hearing rights with members and providers.
• Assign position statements and represent at state hearings.
• Complete other projects and duties as assigned.

Essential Qualifications and Experience

To be successful in this role, you will need:

• An 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 regulations.
• Experience with clinical review processes, including how to analyze and research clinical issues.

Preferred Qualifications and Experience

While not essential, the following qualifications and experience are preferred:

• 5+ years of healthcare/managed care experience, preferably in the following related areas of responsibility: Utilization Management and/or Quality Management.

Skills and Competencies

To excel in this role, you will need to possess the following skills and competencies:

• Strong analytical and problem-solving skills, with the ability to analyze and complete written summaries on clinical cases.
• Excellent communication and interpersonal skills, with the ability to communicate issues clearly and timely to members, providers, involved departments, or health networks.
• Strong organizational and time management skills, with the ability to organize and manage activities related to processing cases within the department.
• Ability to establish and maintain effective working relationships with leadership and staff.
• Proficiency in Microsoft Office, including Excel, Outlook, PowerPoint, Word, and SharePoint.

Career Growth Opportunities and Learning Benefits

At Acentra Health, we're committed to helping our employees grow and develop in their careers. As a Utilization Management Appeals Nurse, you will have access to a range of learning and development opportunities, including training programs, workshops, and conferences. You will also have the opportunity to work with a talented team of professionals who are passionate about delivering high-quality healthcare services.

Work Environment and Company Culture

Acentra Health is a dynamic and supportive work environment that values diversity, equity, and inclusion. We're committed to creating a workplace culture that is collaborative, innovative, and compassionate, and we're looking for individuals who share our values and are passionate about making a positive difference in the lives of our members.

Compensation, Perks, and Benefits

We offer a competitive salary range of $24.00-35.00 per hour, depending on experience and qualifications. Our benefits package includes comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more. We're committed to providing our employees with a rewarding and supportive work environment that recognizes and rewards their contributions.

Conclusion

If you're a motivated and compassionate healthcare professional who is looking for a challenging and rewarding role, we encourage you to apply for this opportunity. As a Utilization Management Appeals Nurse at Acentra Health, you will have the opportunity to make a positive difference in the lives of our members and contribute to the delivery of high-quality healthcare services. Don't miss out on this exciting opportunity to join our team and take your career to the next level. Apply now!

Visit us at Acentra.com/careers/ to learn more about our company and our career opportunities.

Acentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by applicable Federal, State, or Local law.