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CareSource · 3 weeks ago

Clinical Appeals

United States

Full-time

Remote

Mid Level

CareSource is a healthcare organization focused on providing quality care to its members. The Clinical Appeals Nurse is responsible for processing clinical appeals and attending state hearings in compliance with regulatory standards and clinical guidelines, while working closely with medical professionals to resolve complex cases.

Health CareMedicalNon Profit

Comp. & Benefits

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

Qualification

Registered Nurse (RN)Clinical Appeals ExperienceManaged Care KnowledgeMicrosoft Office ProficiencyMCG CertificationMedicaidMedicareCustomer Service OrientedAttention to DetailCommunication SkillsCritical Thinking SkillsTime Management Skills