Clinical Appeals Nurse

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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