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.

Organization Level Competencies

Fostering a Collaborative Workplace Culture

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 environment of belonging that welcomes and supports individuals of all backgrounds.