Health Advocates is seeking a Clinical Appeals Nurse for our main office in Chatsworth, CA.
Job Summary
Reviews medical records and performs clinical reviews to overturn denials and assure billed procedures have medical justification; prepares responses to client disputes. Job responsibilities: reviews all denied cases, performs Medi-Cal utilization reviews using standardized medical review criteria software, completes medical record analysis and abstraction, determine if cases should be appealed, utilize standardized letters to request appeals, determine if patients are eligible for other programs, as needed input data into the computer system to correct detail case specifics, and perform miscellaneous related duties, as needed.
Qualifications
- Licensed LVN/RN
- 3 or more years of clinical experience in a Hospital or Surgical Center
- Clinical auditing and case management utilization review experience
- Prior experience in writing clinical reviews and appeals
- Knowledge of medical terminology
- Knowledge of HMO, PPO, Managed Care, Medicare/Medi-Cal: Acute and Psychiatric services, and private insurance program guidelines
- Knowledge of the Medi-Cal inpatient criteria module of standardized medical review criteria preferred
- Knowledge of Interqual or MCG software preferred
- Knowledge of CCS Eligibility Conditions
- Ability to read and analyze medical records/charts
- Excellent written and verbal communication skills
- Proficient in Microsoft Office
- Must be able to type 30 wpm
Job Requirements:
Working Title: Clinical Appeals Nurse
Pay Rate: Depends on Experience
Position Type: Full-time; Non-Exempt
Schedule: Alternative Work Week Schedule – Mon-Thurs 7:30 am- 5 pm & Fri 7:30 am – 12:30 pm
Other: We conduct assessment testing and post offer background checks
Benefits
Health Advocates offers a comprehensive benefits package to meet the needs of today’s employees. They include: Healthcare and Insurance Benefits, Retirement Benefits, Employee Discounts, Employee Assistance Program, Credit Union, Rideshare Incentives, Employee Referral Program, Vacation/Holiday/Sick Leave and other time off.
About Us
Founded in 1990, Health Advocates is the largest privately funded public advocacy company in California providing Eligibility and Recovery services to California public health systems, private hospitals, clinics, health plans, government agencies, and individuals. We are dedicated to identifying medical coverage from third-party sources such as Medi-Cal, Social Security (SSI/SSDI), and other health insurance programs to minimize uncompensated care to the benefit of both our clients and the patients and applicants they serve. Our success is born from a very unique blend of resources, expertise, and an unwavering determination to identify coverage and recovery solutions on behalf of patients that simply have no ability to pay their increasing financial healthcare debts. Innovation and compassion are integral to Health Advocates’ identity and these attributes have historically served our clients very well. We are proud of our past, excited about our future, and confident of our continued success.
This position requires access to confidential protected health information (PHI). Our employees are expected to protect the privacy of all PHI in accordance with Health Advocates’ privacy policies and procedures and as required by state and federal law including but not limited to the HIPAA Security and Privacy Rule.
Health Advocates
21540 Plummer Street, Suite B
Chatsworth, CA 91311
(818) 995-9500 p
(818) 995-6872 f
Health Advocates is an equal opportunity employer. We believe all of our employees should be treated fairly, consistently, and with dignity and respect. Our goal is to maintain a satisfied and productive team of employees. The keys to reaching that goal are effective leadership, fair and competitive wages and benefits, dedication to the job, and close attention to employee relations matters.