Job Summary:
The Clinical Appeals Nurse is responsible for the completion of clinical appeals and state hearings from all states…
Essential Functions:
Responsible for the completion of clinical appeals and state hearings from all states
Review and complete all provider clinical appeals within required timeframes
Review and complete member clinical appeals within required timeframes
Review all information necessary to prepare State Hearing packets
Communicate with state agencies and internal departments to prepare for State Hearings
Attend assigned State Hearing and complete all required compliances
Complete required compliances for Administrative Hearing decisions
Apply CareSource Medical Policy and Milliman guidelines when processing clinical appeals
Issue notification letters to providers and members
Issue administrative denials appropriately
Refer denials based on medical necessity to medical director
Maintain hardcopy documentation, Facets documentation and appeals database documentation at 90-95% accuracy rates
Conduct monthly, quarterly, and ad hoc appeals reporting
Collaborate with the Quality Improvement and Clinical Operations Team Lead to prepare all requests for Independent External Review
Ensure compliance with regulatory and accrediting requirements
Perform any other job duties as requested
Education and Experience:
RN License required
Associates Degree or equivalent years of relevant experience required
Managed care, appeals, and Medicaid experience preferred
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 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
Familiarity of healthcare field
Knowledge of Medicaid
Flexibility
Change resiliency
Licensure and Certification:
Current, unrestricted license as a Registered Nurse (RN) is required
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
Compensation Range:
$60,300.00 – $96,500.00 CareSource takes into consideration a combination of a candidates education, training, and experience as well as the positions scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employees total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type:
Salary
