Clinical Appeals

CareSource•Indianapolis, IN

About The Position

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

Requirements

Associate’s Degree required
Current, unrestricted license as a Registered Nurse (RN) is required
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
MCG Certification is required or must be obtained within six (6) months of hire

Nice To Haves

Managed care, appeals, Medicare, and Medicaid experience preferred
Prior clinical appeals, and/or Utilization review experience is strongly preferred
Multi-state RN license is preferred

Responsibilities

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