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Corporate Functions & Operations WellCare - Operations Management Careers

Clinical Appeals LPN Job

Full Job Title: Clinical Appeals LPN

Job Number: 1700111

Location: Tampa, FL

Date Posted: 12-13-2017

Responsible for preparing cases for physician review and all appeal related activities accurately, efficiently, and within mandated timeline requirements. Performs appeal reviews on medical and/or behavioral health records and cases utilizing established guidelines and member benefit plans. Communicates the outcome of the appeals process with members, internal and external partners.

Department: Health Services

Reports to: Mgr, Appeals

Location: Tampa, FL 33634

Essential Functions:

  • Utilizes WellCare designated criteria along with clinical knowledge to make authorization decisions and assist the Medical Director with appeal determinations.
  • Collects information concerning eligibility, provider status, benefit coverage, coordination of benefits and subrogation necessary to reach prospective, concurrent and retrospective decisions in the appeals process. Reviews and interprets a variety of instructions and medical notes furnished in written and oral form to determine appropriate action towards appeal.
  • Applies regulatory requirements and accreditation standards to all review activity and reporting.
  • Applies accepted criteria to review process, utilizes the parameters and inputs review data into systems.
  • Prepares and submit projects, reports or assignments as needed to meet department initiatives and/or objectives.
  • Produces approval and/or denial letters on behalf of the Medical Director for submission to member, provider or hospital.
  • Ensures quality customer service, maintenance of confidentiality, and assistance in identifying process improvement opportunities related to appeals processing.
  • Ensures accurate data entry into the medical management system, including but not limited to appropriate procedure and diagnosis codes, approved abbreviations and relevant clinical information documented per departmental policies.
  • Performs special duties as assigned.

Licenses and Certifications:

  • A license in one of the following is required:
    • LPN, RN, LSW, LMHC, or LCSW

Candidate Minimum Education:

  • Required A High School or GED

Candidate Experience:

  • Required: 2 years of experience in a clinical setting with general nursing exposure in utilization management (UM), to include pre-authorization, utilization review, concurrent review, discharge planning, case management with review, and/or skilled nursing facility reviews.
  • Preferred: 2 years of experience in an acute care clinical setting (medical and/or behavioral health)
  • Preferred: 2 years of experience in managed care

Candidate Skills:

  • Advanced ability to create, review and interpret treatment plans
  • Advanced ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
  • Advanced knowledge of medical terminology and/or experience with CPT and ICD-9 coding
  • Intermediate knowledge of community, state and federal laws and resources

Technical Skills:

  • Intermediate proficiency in Microsoft Outlook, Word, Excel, and PowerPoint
  • Intermediate proficiency in a healthcare management system
  • Ability to use a proprietary healthcare management system

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Last Updated On: 12/9/2015