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:

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 (hourly/salary):

Organization Level 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.