Company Description

Job Description

The Clinical Appeals Nurse is responsible for the completion of clinical appeals and state hearings from all states.

Requirements

Education and Experience: RN License required Associates Degree or equivalent years of relevant experience required Managed care, appeals, and Medicaid experience preferred 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 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 Licensure and Certification: Current, unrestricted license as a Registered Nurse (RN) is required 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

Responsibilities

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

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