Clinical Appeals Nurse

Job Description

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 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. We are highly invested in every employee?s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type:
Salary

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