LPN Clinical Research Coordinator

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Requirements:

• High school diploma or equivalent required.
• Licensed Practical Nurse (LPN) with current active state license in the state(s) where job duties are performed required.
• Minimum four (4) years' clinical nursing experience, to include a broad background in various facets of nursing.
• Knowledge of HCPCS/CPT/Revenue codes and general coding principles.
• Knowledge of claims processing rules/logic.
• Knowledge of Health Plan operations, regulatory agencies and State/Federal regulations related to health care.
• Minimum two (2) years' utilization review, medical policy, and/or case management experience required.
• Previous experience in appeals and/or grievances process preferred.
• Excellent Oral & Written Communication
• Detail-Oriented
• Strong analytical, critical thinking, organizational and time management skills
• Proficiency using basic computer skills in Microsoft Office such as Word, Excel, Outlook, and PowerPoint, including the ability to navigate multiple systems and keyboarding.
• Ability to make sound judgments and decisions based on facts and guidelines.
• Ability to build collaborative relationships.
• Ability to work independently with little supervision.
• Ability to interpret complex documentation.

Responsibilities:

• Serves as a liaison facilitating a collaborate process between multiple internal functional areas, clinical leadership, primary physicians, patients and Medical Director to assist with escalated cases that requires input from multiple areas with the enterprise, providers, facilities and vendors.
• Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.
• Integrates data from multiple data sources or functional areas, ensures data accuracy and integrity, and updates data as needed to develop models to be used for decision making and initiatives
• Remain current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts.
• Other duties as assigned.
• Serves on various committees and project teams related to policy changes, system enhancements, process improvement initiatives, etc.
• Monitors and evaluates data and processes to ensure accuracy and identify changes to increase efficiency and effectiveness.
• Serves as a resource to Medical Director(s) and Care Management team providing analysis, reporting and research on medical conditions, medical terminology, medications, lab work, medical records, healthcare processes, coverage policies, plan guidelines, and/or health/wellness.