Clinical Appeals

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:

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/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business