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Denial Review Nurse, LVN

Company: Apollo Medical Holdings, Inc.
Location: Monterey Park
Posted on: May 3, 2021

Job Description:

SUMMARY

Denial Nurse Reviewer ensures accurate processing of all written notifications created by the denial team. Ensuring that all deferral and denial letters are written according to NMM Policies and meet all NCQA, Health Plan, Federal and State requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES

* Comply with NMM and department policies and procedures to accurately process of all denials. * Review all written denial letters according to State and Federal regulations, NMM policy and appropriate level of decision making responsibility * Ensure appropriate denial template and corresponding "Your Rights" attachments is selected according to Health Plan, Line of Business (LOB), based on hierarchy and threshold language. * Ensure Diagnosis, denial, criteria and NOA language correspond * Ensure template contains clarifying statement to indicate that beneficiaries may request, free of charge, copies of all documents and records relevant to the NOA, including criteria or guidelines used * When used, ensure appropriate use of extensions granted either for the member or provider who requested the extension or it is justified as a need for additional information and is in the member's best interest. (Title 42, CFR, Section 438.210(d)(1)) * Evaluate decisions based in whole or in part on medical necessity, the written NOA shall contain all of the following: * A statement of the action intended. * A clear and concise explanation of the reasons for the decision. Ensuring NOA provides member and practitioners enough information to help them understand the decision to deny care or coverage and how to appeal the decision. That denial verbiage is at the appropriate grade level based on LOB. * A description of the criteria or guidelines used. This includes a reference to the specific regulation or authorization procedures that support the decision, as well as an explanation of the criteria or guideline. Ensures the use of appropriate criteria is referenced in NOA and EZCap matching letters to original diagnosis, CPT codes and progress of the referral * For written notification to the provider, the name and direct telephone number or extension of the decision maker. * Check and report UM Coordinator (level 1) and clinical reviewer have documented reason for denial in EZCap * Check and report compliance with Turn Around Time (TAT) guidelines. (HSC Section 1367.01(h)(3)) * Ensure denial packet has been reviewed and completed prior to finalizing. Complete denial packets consist of the denial letter, authorization request, evidence of receipt for member/provider, clinical guidelines and medical records

OTHER RESPONSIBILITIES:

* Weekly monitoring of staff effectiveness and error report and report to Denials Supervisor * Assist UM Denial Supervisor in internal audits as needed with feedback to the supervisor to improve quality * Demonstrate ethical commitment to quality assurance, efficient utilization of resources and confidentiality of all data and information. * Demands creativity, flexibility and the ability to work under stress both with and without supervision. * Reports to UM Denial Manager on activities or problems occurring throughout the day. * Performs other duties, projects and actions as assigned. * Maintains strictest confidentiality at all times.

QUALIFICATIONS:

* Unrestricted Licensed Nurse, RN or LVN * A minimum of two years experienced in managed care environment to include but not limited to an IPA or MSO preferred. * Current knowledge of Managed Care UM procedures * Knowledge of medical terminology, RVS, CPT, HPPCS, ICD-9 codes. * Proficient with Microsoft applications' and EZCAP * Good organizational skills. * Good verbal and written communication skills.

8. Must have the ability to multitask and problem solve in a fast pace work environment

9. Personal & Professional Qualities

* Punctuality, precision with details, creativity, etc. would be helpful for this position * Ability to follow directions and perform work independently according to department standards * Able to function effectively under time constraint * Able to maintain confidentiality at all times * Willingness to accept responsibility and desire to learn new task * Ability to comply and follow company policies and procedures * Must be a strong team player, punctual and have excellent attendance record.

Keywords: Apollo Medical Holdings, Inc., Monterey Park , Denial Review Nurse, LVN, Other , Monterey Park, California

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