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Job Summary
The Clinical Appeals Nurse is responsible for processing clinical appeals and attending state hearings within compliance and regulatory standards, clinical guidelines, and contractual obligations.
Job Summary
The Clinical Appeals Nurse is responsible for processing clinical appeals and attending state hearings within compliance and regulatory standards, clinical guidelines, and contractual obligations.
Essential Functions
Responsible for the completion of clinical appeals and state hearings from all states
Perform clinical reviews of member and provider appeals for medical, dental, behavioral health, pharmacy, and waiver services
Analyze medical records, supporting documentation, and applicable guidelines to make informed decisions
Document clinical rationale clearly and accurately in alignment with organizational and regulatory standards
Work closely with medical directors, and pharmacists to resolve complex cases.
Communicate outcomes effectively to members, and providers.
Review and complete all provider clinical appeals within required timeframes
Review and complete member clinical appeals within required timeframes
Communicate with state agencies and internal departments to prepare for State Hearings
Apply CareSource Medical Policy and Milliman guidelines when processing clinical appeals
Issue administrative denials appropriately
Refer denials based on medical necessity to medical director
Collaborate with the Quality Improvement and Clinical Operations teams to prepare all requests for Independent External Review
Participate in training programs to maintain clinical and regulatory expertise.
Perform any other job duties as requested
Education And Experience
Associate’s Degree required
Managed care, appeals, Medicare, and Medicaid experience preferred
Prior clinical appeals, and/or Utilization review experience is strongly preferred
Competencies, Knowledge And Skills
Intermediate proficiency with Microsoft Office products and Facets
Knowledge of NCQA, URAC, OAC, and MDCH regulations
Strong clinical judgment
Attention to detail
Ability to navigate complex regulations while maintaining a commitment to high-quality care
Strong written and oral communication skills
Ability to work independently and within a team environment
Critical listening and thinking skills
Proper grammar usage
Time management skills
Proper phone etiquette
Customer Service oriented
Decision making/problem solving skills
Knowledge of Medicaid, and Medicare,
Flexibility
Change resiliency
Licensure And Certification
Current, unrestricted license as a Registered Nurse (RN) is required
Multi-state RN license is preferred
MCG Certification is required or must be obtained within six (6) months of hire
Working Conditions
General office environment; may be required to sit or stand for extended periods of time
Position requires the flexibility to work weekends, evenings, and/or holidays, as needed
Compensation Range
$61,500.00 - $98,400.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type
Hourly
Competencies
Create an Inclusive Environment - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.
Seniority level Seniority level Entry level
Employment type Employment type Full-time
Job function Job function Health Care Provider
Industries Insurance
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