Remote Appeals Clinical Review LPN

Responsibilities

• Review and evaluate member and provider appeals related to medical necessity determinations, authorization decisions, and claims outcomes.
• Apply clinical expertise and evidence-based guidelines to ensure accurate, fair, and consistent appeal determinations.
• Ensure all appeal decisions comply with applicable regulatory requirements, Medicaid guidelines, and organizational policies.
• Document appeal reviews and determinations clearly, accurately, and in a timely manner within designated systems.
• Collaborate with Medical Directors to clarify complex clinical issues and support final appeal decisions.
• Work closely with providers to gather necessary clinical information and explain appeal outcomes as appropriate.
• Cook with claims teams to address claims-related appeals and ensure correct processing based on determinations.
• Partner with utilization management staff to align appeal decisions with utilization review processes and criteria.
• Support quality patient care by balancing member needs with appropriate utilization of healthcare services.
• Maintain confidentiality and handle sensitive member and provider information in accordance with all policies and regulations.

Requirements

• Active Florida Licensed Practical Nurse (FL LPN) credential.
• At least 2 years of utilization management (UM) and utilization review (UR) experience.
• At least 2 years of experience working with Medicaid populations or Medicaid programs.
• Demonstrated experience in clinical review within a managed care or similar environment.
• Strong understanding of medical necessity criteria, authorization processes, and claims outcomes.
• Ability to interpret and apply evidence-based guidelines and regulatory requirements to appeal determinations.
• Proficiency in remote work tools and electronic documentation systems.
• Excellent critical thinking, clinical judgment, and decision-making skills.
• Strong written and verbal communication skills for interaction with Medical Directors, providers, and internal teams.
• Able to manage time effectively and complete appeal reviews within required timelines.

Qualifications

• Experience in utilization management and utilization review within a managed care setting.
• Familiarity with Medicaid regulations and program requirements.
• Comfort working in a collaborative, cross-functional environment with Medical Directors, providers, claims teams, and utilization management staff.
• Attention to detail and accuracy in documentation and clinical review.
• Ability to adapt to changing guidelines, policies, and regulatory requirements.
• Interest in long-term opportunities, including potential transition to a permanent position.

Pay and Benefits

The pay range for this position is $28.00 - $33.00/hr.

Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:

• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 20,000 consultants and 5,000 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500. We are proud to be an Engineering News-Record (ENR) Top 500 Design Firm for our engineering design services and a ClearlyRated Best of Staffing® winner for both client and talent service. The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law. If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation options.