Lumeris Appeals Registered Nurse in St. Louis, Missouri

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Position:

Appeals Registered Nurse

Position Summary:

The Appeals Nurse conducts the clinical review of inpatient and outpatient pre-service appeal requests including Acute care, Skilled Nursing Facilities, Outpatient services, Home Health Care and other Benefit Determination requests. All reviews are conducted in accordance with departmental and Medicare guidelines. The Appeals Nurse acts as a liaison to the Medical staff for all appeals related activity. In addition, the Appeals Nurse serves as a clinical resource to non-clinical staff for case preparation and review for all levels of reconsiderations and redeterminations.

Job Description:

Responsibilities:

  • Perform medical record reviews of requested services within specified department timelines.

  • Apply advanced clinical knowledge for the interpretation and evaluation of clinical data in order to determine compliance with established criteria

  • Prepare case documents for cases requiring physician review to ensure a comprehensive clinical picture is presented facilitating accurate and timely decision making by the physician

  • Process appeals from investigation to resolution according to CMS regulations and department policies and procedures within the timeliness standards

  • Prepare and present select appeals to the multi-disciplinary Appeals Committee.

  • Complete post-service requests for claim redetermination reviews as requested.

  • Document completely and accurately within an electronic clinical record

  • Provide education on the appeals process to members and providers as requested

  • Maintain HIPAA standards and ensure confidentiality of protected health information

  • Ensure compliance with all state and federal regulations and guidelines in day-to-day activities

  • Perform special projects as assigned

Experience:

  • Licensed Registered Nurse (RN) in the state of Missouri is required, eligible for licensure in other states as required

  • Minimum 5 years clinical nursing experience required

  • 2+ years experience utilization review, denial management, audits and appeals, clinical documentation improvement or related expertise

  • Proficient knowledge of Medicare/Managed Care guidelines preferred

  • Working knowledge of medical necessity criteria

Knowledge, skills, and ability required:

  • Strong verbal and written communication skills

  • Strong problem solving skills

  • Strong attention to details

  • Strong customer service skills

  • Excellent organization skills for prioritizing tasks to meet set deadlines

  • Ability to multi-task and self-motivate

  • Proficient knowledge of Medicare and HIPAA regulations

  • Professional demeanor and the ability to work effectively within a team or independently

  • Strong computer skills including Microsoft Office

  • 1+ years of experience in Appeals, preferred

  • 1+ years of experience in Managed Care preferred

Lumeris is an EEO/AA employer M/F/V/D.

Location:

St. Louis, MO

Time Type:

Full time

Status:

XL - FT

Join Our Growing Team!

Lumeris serves as a long-term operating partner for organizations that are committed to the transition from volume- to value-based care and delivering extraordinary clinical and financial outcomes. Lumeris enables clients to profitably achieve greater results through proven playbooks based on collaboration, transparent data and innovative engagement methodologies. Lumeris offers comprehensive services for managing all types of populations, including launching new Medicare Advantage Health Plans, Commercial and Government Health Plan Optimization, and Multi-Payer, Multi-Population Health Services Organizations (PHSOs). Currently, Lumeris is engaged with health systems, provider alliances and payers representing tens of millions of lives moving to value-based care.

Over the past seven years, we have tripled in size to more than 800 employees and built the only solution on the market with our proven outcomes. For the past six years, Essence Healthcare, a long-standing Lumeris client, has received 4.5 Stars or higher from the Centers for Medicare and Medicaid Services (CMS). Essence Healthcare was Lumeris’ pioneer client and has been leveraging Lumeris for more than a decade to operate its Medicare Advantage plans, which serve more than 60,000 Medicare beneficiaries in various counties throughout Missouri and southern Illinois.

In 2018, Lumeris was named Best in KLAS for Value-Based Care Managed Services in the area of client-reported impact on the Triple Aim by KLAS Research. This was the third year in a row Lumeris received the award, and it has only been given for three years. As the industry’s most reliable and effective partner for developing population health management solutions, our success is driving tremendous growth in our company. Join us today in making a real difference in how healthcare is delivered!

Why Join Lumeris?

At Lumeris, you will be part of team that is focused on solving the nation’s healthcare problem, and you will be able to contribute to our purpose. Our environment is fast-paced, change-oriented and focused on growth and employee engagement. At Lumeris, we know that talent is best utilized when given the opportunity to succeed. That is why we have removed the boundaries that inhibit success and focus on fostering an environment that allows employees to utilize their talents.