Coding Appeals Nurse Associate - LPN/LVNPrimary Location: Hartford, CT
Additional Locations: AZ-Phoenix, CT-Hartford, DE-Wimington, FL-Miami, FL-Orlando, IL-Chicago, KS-Wichita, NE-Omaha, NJ-New Brunswick, OH-Akron, PA-Allentown, PA-Philadelphia, TN-Memphis, TX-Amarillo, TX-Dallas, TX-Houston, TX-San Antonio, VA-Chantilly, VA-Richmond Apply
Responsible for the review and resolution of clinical complaints and appeals. Interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required.
Requires unrestricted and active LPN/LVN license.
64981Fundamental Components: - Assists with reviewing complaint / appeal requests of all clinical determinations/clinical policies. Considers all previous information as well as any additional records/data presented to prepare a recommendation.
- Assists with data gathering that requires navigation through multiple system applications.
- Contacts the provider of record, vendors, or internal Aetna departments to obtain additional information.
- Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the appeal issue at hand (e.g. Specialty Match Review (SMR), RN, MD, etc.).
- Commands a comprehensive knowledge of complex delegation arrangements, coding logic, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, and ERO eligibility which are required to support the appeals determinations.
- Proactively and consistently applies the regulatory and accreditation standards to assure that appeals and ERO requests are processed within requirements.
-Assists with condensing information from multiple sources (i.e., contract, coding, regulatory, etc.) into a clear and precise clinical picture for presentation to an appropriate clinician for determination.
- Seeks guidance from other healthcare professionals in the coordination and administration of the appeals process Background Experience: - 2+ years of clinical experience required.
- Unrestricted and active State LVN/LPN licensure required.
- Managed Care experience preferred.
Additional Job Information: Typical office working environment with productivity and quality expectationsWork requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.Ability to multitask, prioritize and effectively adapt to a fast paced changing environmentPosition requires proficiency with computer skills which includes navigating multiple systems and keyboardingEffective communication skills, both verbal and written. Functional Skills: Nursing - Clinical claim review and coding Technology Experience: Aetna Application - Aetna Total clinical View, Desktop Tool - Microsoft Outlook Potential Telework Position: Yes Percent of Travel Required: 0 - 10% EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer Benefit Eligibility: Benefit eligibility may vary by position. Click here to review the benefits associated with this position. Candidate Privacy Information: Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.
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