Denials, Grievances and Appeals LVN - Utilization Management - Southwestern Health Resources (SWHR)

Here’s What You Need

Education

• High School Diploma or Equivalent required.
• Must be a graduate of an accredited Licensed Vocational Nursing (LVN) program.

Experience

• Require 2 years of Medicare Advantage experience.
• Require 2 years of Utilization Management, Clinical Administration, Denials/Grievances/ and Appeals, Health Plan or ACO Administration experience.

Licenses & Certifications

• Current and active State of Texas Licensed Vocational Nurse (LVN) License upon hire required. 
• Certified Case Manager (CCM) Certification upon hire preferred. 

Skills & Abilities

• Working knowledge of computers and basic software application used in job functions such as word processing, graphics, databases, spreadsheets, etc.
• Strong analytical and organizational skills.
• Working knowledge and ability to apply professional standards of practice in work environment.
• Knowledge of specific regulatory, Texas Department of Insurance statutes, NCQA, URAC, CMS, and managed care requirements.

What You Will Do

Position Responsibilities

Under the direction of the Denials, Grievances & Appeals RN, the LVN will use their clinical knowledge, experience, and advanced critical thinking to ensure accuracy and integrity of the full life cycle of medical necessity denial determinations is properly administered. This includes ensuring language utilized in denial determination letters is clear, compliant, clinically sound, professional, accurate, and aligns with clinical requirements relative to regulatory, state, and federal documentation requirements.

Position Functions

• Evaluate letter correspondence for content, clarity, accuracy, and consistency.
• Communicate effectively and clearly both orally and in writing to leaders, clinical and non-clinical staff, as well as administrative and clerical personnel.
• Work as a team to complete departmental tasks to meet deadlines and accomplish department objectives.
• Complete a thorough review of all letters, utilizing the recommendations, guidance, and direction from the Denials, Grievances and Appeals RN and internal SWHR resources.
• Meet with leadership to discuss questions or issues regarding workload, request guidance, and/or disseminate feedback or concerns stemming from letter correspondence.
• Develop and sustain effective and professional working relationships with peers, leaders, and internal teams.
• Under the supervision of the Denials, Grievances and Appeals RN, assist with projects and initiatives as needed.
• Package & send appeal and grievance information to the HP, monitors for the outcome of appeal and takes action accordingly (notify the provider and member as per delegation agreement), track all appeal information.
• Schedule peer to peer calls with UM MD for denied cases.
• Provide after-hours coverage for appeals and documents accordingly.
• Perform other duties as assigned.

Why Southwestern Health Resources 

As a Southwestern Health Resources employee, you’ll enjoy, comprehensive benefits, including a 401(k) with match; paid time off; competitive health insurance choices; healthcare and dependent care spending account options; wellness programs to keep you and your family healthy; tuition reimbursement; a student loan repayment program; and more.

• Additional perks of being an SWHR employee:
• Gain a sense of accomplishment by contributing to a teamwork environment.
• Positively impact patients’ quality of life.
• Receive excellent mentorship, comprehensive training and dedicated clinical and administrative leadership resources.
• Enjoy opportunities for growth.

Explore Southwestern Health Resources Careers for more information and to search all career opportunities.

Our Recruitment team invites you to contact us with any questions at recruitment@texashealth.org