Remote HEDIS LPN

Actalent is Hiring a Team of Remote HEDIS LPN/RN

Job Description

This role involves facilitating medical necessity appeals and denials, including reviewing clinical information to determine if medical necessity criteria are met. The position plays a critical role in ensuring compliance with company policies and NCQA guidelines.

Responsibilities

• Review clinical data to determine claim payment based on company policies and NCQA guidelines.
• Overturn denied claims, uphold denials, and submit cases to the Medical Director for review.
• Prepare case reviews for the Medical Director when criteria are not met based on additional clinical information received.
• Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines.
• Create system authorization events for overturned denial decisions.
• Request additional information from providers to facilitate timely appeals resolution.
• Gather and prepare case information for Administrative Law Hearings.
• Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database.
• Assist the Medical Director with revising, updating, and creating new policies to satisfy NCQA and contractual requirements.

Essential Skills

• LPN with 3 years of clinical nursing experience or RN with 2 years of clinical nursing experience.
• Proficient with Microsoft Office applications.
• Experience with utilization or appeals review preferred.
• Knowledge of InterQual criteria preferred.
• RN or LPN license required.
• For candidates in New York, a NYS RN license is required.

Additional Skills & Qualifications

• Managed care experience.
• Quality Improvement experience.
• HEDIS experience.

Work Environment

This position is within a healthcare setting where compliance with NCQA guidelines is crucial. The candidate will be required to work with various technologies and software applications to facilitate the appeals process. The role may involve interactions with medical professionals and participation in Administrative Law Hearings.

Job Type & Location

This is a Contract position based out of Nashville, TN.

Pay and Benefits

The pay range for this position is $36.00 - $38.00/hr.

Eligibility requirements apply to some benefits and may depend on your job
classification and length of employment. 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)

Workplace Type

This is a fully remote position.

Application Deadline

This position is anticipated to close on Nov 20, 2025.

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 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

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 due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation options.

Salary : $36 - $38