Clinical Appeals Nurse - PST Hours Required

CareSource

About The Position

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: $62,700.00 - $100,400.00 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. 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): Hourly 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. #LI-JS1 The CareSource mission is known as our heartbeat. Just as we support our members to be the best version of themselves, our employees are driven by our mission to create a better world for members, stakeholders and providers. We are difference-makers who combine compassionate hearts with our unique business expertise to make every opportunity count. Each claim, each phone call, each consumer-centric decision is a chance to change the world for one member, and our employees look for ways to do that every day. The challenge is, there is no one right way to be the difference and we’re looking for people like you that will rewrite that definition every day. We do what it takes to form creative solutions that make our community and the world just a little better. Discover what it means to be #UniquelyCareSource.

Requirements

Associate’s Degree 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
Current, unrestricted license as a Registered Nurse (RN) is required
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

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