Manager, Clinical Appeals

CareSource•Indiana WFH, IN

6d•$83,000 - $132,800

About The Position

The Manager, Clinical Appeals oversees clinical appeals activities to ensure consistent services and achievement of compliance targets. The role coordinates and manages appeals related to adverse benefit determinations, ensures consistent application of review criteria, and oversees data and processes so decisions meet industry standards and required timeframes. The manager works with providers and staff to administer benefits in alignment with state regulations, NCQA standards, and CareSource policies. The position monitors productivity, turnaround times, and volume trends; reviews workflows for efficiency; oversees continuous quality improvement activities and audits; and maintains regulatory reporting, policies, procedures, and trend data. It also analyzes utilization and appeal outcome data to assess effects on member care and outcomes and develop recommendations. The manager audits case documentation and interrater reliability and serves as a liaison with other departments. Other job-related duties may be assigned.

Requirements

Associate’s Degree in Nursing.
Minimum of five years of clinical experience.
Minimum of five years of experience in utilization management, appeals, and/or quality improvement.
Current, unrestricted Registered Nurse (RN) licensure in the state of practice.
MCG Certification is required or must be obtained within six months of hire.
Beginning-level experience with Excel, Word, and PowerPoint.
Experience in data analysis and trending.
Knowledge of utilization management standards and practices.
Communication skills.
Management and prior supervisory skills.
Ability to work independently and within a team environment.
Attention to detail and familiarity with the health care field.
Critical listening and thinking skills.
Training and teaching skills.
Strategic management skills.
Negotiation skills or experience.
Proper grammar usage and technical writing skills.
Change resiliency and time management skills.
Proper phone etiquette and customer-service orientation.
Decision-making and problem-solving skills.
Leadership experience and skills.

Nice To Haves

Bachelor of Science in Nursing (BSN).
Two years of utilization management or appeals experience.
Minimum of two years of leadership experience.
Managed care leadership experience.

Responsibilities

Coordinate and manage the clinical appeals process related to adverse benefit determinations.
Ensure consistent application of criteria during the clinical appeals process.
Oversee clinical appeals data and processes to maintain industry standards and practices, including decisions within allowable timeframes.
Interact with providers and staff to manage benefits in alignment with state-based regulations, NCQA, and CareSource policies.
Review and revise workflows to maximize efficiency.
Monitor productivity, turnaround time, and volume trends.
Oversee continuous quality improvement activities and ensure audits and staff feedback occur regularly.
Regularly report clinical appeals regulatory requirements and ensure compliance with and reporting of all regulatory requirements.
Maintain clinical appeals reporting and trend data.
Analyze under- and over-utilization information for impacts on member quality of care and outcomes, and formulate recommendations based on data.
Analyze state hearing, non-formulary exception, external, and Independent Review Entity outcome data and formulate recommendations based on findings.
Develop, maintain, and update departmental policies and procedures; ensure notices of adverse action are provided in accordance with required regulations.
Audit clinical appeal cases for documentation and interrater reliability in accordance with CareSource policy.
Act as a liaison with other departments to assist with research and intervention.
Perform other job-related instructions as requested.