Payment Integrity - Clinical LPN

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The Payment Integrity - Clinical LPN supports the clinical and administrative coordination of Single Case Agreements for out-of-network services. This role partners closely with Care Management, Payment Integrity, Cost Containment, and Provider Relations to ensure SCA requests are complete, clinically supported, timely, and compliant with internal policies and client plan requirements. The LPN serves as a key point of contact for gathering documentation, tracking SCA status, and facilitating communication between internal teams and external providers.

What You'll Actually Do: Receive, review, and track Single Case Agreement (SCA) requests for completeness and accuracy, ensuring required clinical and demographic information is obtained prior to submission. Support Care Managers and Payment Integrity teams by gathering clinical documentation that substantiates medical necessity for out-of-network services. Enter, update, and maintain SCA requests in designated systems (e.g., Smartsheet, case management platforms), ensuring accurate status tracking and documentation. Clinical & Administrative Support: Review member eligibility, benefits, and plan provisions related to out-of-network services and Single Case Agreements. Assist in identifying appropriate scenarios for SCA consideration, including continuity of care, lack of in-network availability, or specialized services. Collaborate with internal clinical staff (RNs, Care Managers, Medical Directors) to escalate cases requiring clinical review or urgent handling. Provider & Internal Communication: Serve as a liaison between providers, internal clinical teams, and Payment Integrity regarding SCA documentation requirements and next steps. Communicate professionally with provider offices to obtain missing information, clarify services requested, and support timely SCA processing. Document all communications and actions in accordance with internal SOPs and compliance standards. Compliance & Quality: Adhere to established Single Case Agreement policies, workflows, and turnaround time expectations. Ensure all SCA activity aligns with regulatory, contractual, and client-specific requirements. Participate in quality audits, process improvement initiatives, and training related to SCA workflows.