Clinical & Nursing
LVN, UM Appeals
Austin, TX, United States

This position will be starting 1/7/2019

LVN, UM Appeals


Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans.

Are we growing? Absolutely—56.7% in year-over-year revenue growth in 2016. Are we recognized? Definitely. We have been named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016 and 2017, and one of the “50 Great Places to Work” in 2017 by Washingtonian, and our CEO was number one on Glassdoor’s 2015 Highest-Rated CEOs for Small and Medium Companies. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.



Position Summary

The Grievance and Appeals Nurse is responsible for handling the clinical components of the grievance and appeals process for Valence Health and applicable clients. The position ensures that clinical grievances and appeals are processed in accordance with federal and state laws and regulations, contract provisions, accreditation standards, and internal policies and procedures.

Essential Functions Conducts Standard and Expedited Medical Appeals Processes in compliance with applicable federal and state regulatory requirements, contracts, and national accreditation standards.

  • Gathers and provides documentation and research outcomes within required time frames to Clients who manage their own appeals.
  • Ability to interpret and operationalize multiple regulatory requirements and differences in each.
  • Ability to multitask and respond quickly and accurately to issues and concerns for members and internal departments.
  • Collaborates with appropriate staff to resolve member and provider clinical Grievances; formulate improvement measures and responses; prepare written correspondence to member and others as required.
  • Other duties as assigned

Education and Experience

  • LVN
  • Minimum of three years of direct clinical patient care
  • Minimum of three years of experience with medical management activities in a managed care environment
  • Knowledge of managed care principles, HMO and Risk Contracting arrangements.
  • Knowledge of CMS (Medicare/Medicaid) regulations and requirements
  • Experience with clinical decision-making criteria sets (i.e. Milliman, InterQual)
  • Strong interpersonal, oral and written communication skills.
  • Possess basic computer skills

 

Evolent Health is an Equal Opportunity/Affirmative Action Employer

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