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Clinical Appeals Nurse
Dayton, OH
Job Description
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 completed 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.
Education and Experience:
* RN License required.
* Associate 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.
It is the policy of the Company to provide equal employment opportunities to all qualified individuals and to administer all aspects and conditions of employment without regard to the following:
• Race and associated traits, including hairstyle; Color, Age, Sex, Sexual orientation, Gender, Gender identity and gender expression; Religion, including dress and grooming practices; National origin, including language use restrictions; Pregnancy, childbirth, or breastfeeding; Marital or familial status; Genetic information, including family medical history; Physical or mental disability; Citizenship and/or immigration status
• Medical conditions, including cancer, AIDS/HIV, and occupational pneumoconiosis without respiratory impairment
• Denial of family or medical care leave
• Use of a guide or support animal
• Military or veteran status
• Political activities or affiliations
• Exercise of civil rights
• Domestic violence, assault, or stalking victim status
• GED certificate
• Arrest, expunged, or sealed records
• Application for or enrollment in Medi-Cal
• Status as a smoker or non-smoker
• Credit report or credit information
• Child or spousal support withholding
• Wage garnishment for consumer debt
• Relationship with someone with a disability
• Lawful conduct occurring during nonworking hours not on Company premises
• Any other protected class, in accordance with applicable federal, state, and local laws
Discriminatory, harassing, or retaliatory behavior is prohibited from coworkers, supervisors, managers, owners, and third parties, including clientele. The Company takes allegations of discrimination, harassment and retaliation very seriously and will promptly conduct an investigation when warranted. Equal employment opportunity includes, but is not limited to, employment, training, promotion, demotion, transfer, leaves of absence and termination.
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 completed 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.
Education and Experience:
* RN License required.
* Associate 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.
It is the policy of the Company to provide equal employment opportunities to all qualified individuals and to administer all aspects and conditions of employment without regard to the following:
• Race and associated traits, including hairstyle; Color, Age, Sex, Sexual orientation, Gender, Gender identity and gender expression; Religion, including dress and grooming practices; National origin, including language use restrictions; Pregnancy, childbirth, or breastfeeding; Marital or familial status; Genetic information, including family medical history; Physical or mental disability; Citizenship and/or immigration status
• Medical conditions, including cancer, AIDS/HIV, and occupational pneumoconiosis without respiratory impairment
• Denial of family or medical care leave
• Use of a guide or support animal
• Military or veteran status
• Political activities or affiliations
• Exercise of civil rights
• Domestic violence, assault, or stalking victim status
• GED certificate
• Arrest, expunged, or sealed records
• Application for or enrollment in Medi-Cal
• Status as a smoker or non-smoker
• Credit report or credit information
• Child or spousal support withholding
• Wage garnishment for consumer debt
• Relationship with someone with a disability
• Lawful conduct occurring during nonworking hours not on Company premises
• Any other protected class, in accordance with applicable federal, state, and local laws
Discriminatory, harassing, or retaliatory behavior is prohibited from coworkers, supervisors, managers, owners, and third parties, including clientele. The Company takes allegations of discrimination, harassment and retaliation very seriously and will promptly conduct an investigation when warranted. Equal employment opportunity includes, but is not limited to, employment, training, promotion, demotion, transfer, leaves of absence and termination.
Job Summary
Start Date
As soon as possible
Employment Term and Type
Regular, Full Time
Required Education
Associate Degree
Required Experience
Open
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