REMOTE - Clinical Appeals Nurse - UM/Appeals Experience(WEEKEND INCLUDED) - R7472
REMOTE - Clinical Appeals Nurse - UM/Appeals Experience(WEEKEND INCLUDED) - R7472
CareSource
United States
See who CareSource has hired for this role
Job Summary
**One must be willing to work weekends**
The Clinical Appeals Nurse is responsible for the completion of clinical appeals and state hearings from all states.
Essential Functions
$60,300.00 - $96,500.00 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. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type
Salary
Competencies
**One must be willing to work weekends**
The Clinical Appeals Nurse is responsible for the completion of clinical appeals and state hearings from all states.
Essential Functions
- Responsible for the completion of clinical appeals and state hearings from all states
- Review and complete all provider clinical appeals within required timeframes
- Review and complete member clinical appeals within required timeframes
- Review all information necessary to prepare State Hearing packets
- Communicate with state agencies and internal departments to prepare for State Hearings
- Attend assigned State Hearing and complete all required compliances
- Complete required compliances for Administrative Hearing decisions
- Apply CareSource Medical Policy and Milliman guidelines when processing clinical appeals
- Issue notification letters to providers and members
- Issue administrative denials appropriately
- Refer denials based on medical necessity to medical director
- Maintain hardcopy documentation, Facets documentation and appeals database documentation at 90-95% accuracy rates
- Conduct monthly, quarterly, and ad hoc appeals reporting
- Collaborate with the Quality Improvement and Clinical Operations Team Lead to prepare all requests for Independent External Review
- Ensure compliance with regulatory and accrediting requirements
- Perform any other job duties as requested
- RN License required
- Associates Degree required
- Managed care, appeals with Medicaid. Commercial, and/or Medicare experience preferred
- Utilization review experience is strongly preferred
- Intermediate proficiency with Microsoft Office products and Facets
- Knowledge of NCQA, URAC, OAC, and MDCH regulations
- 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
- Familiarity of healthcare field
- Knowledge of Medicaid
- 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
- General office environment; may be required to sit or stand for extended periods of time
$60,300.00 - $96,500.00 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. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type
Salary
Competencies
- Create an Inclusive Environment - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business
-
Seniority level
Entry level -
Employment type
Full-time -
Job function
Health Care Provider -
Industries
Insurance
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