[Remote-Position] Clinical Appeals Nurse

We are currently looking for a skilled and motivated Clinical Appeals Nurse! Experience the best of both worlds with this role based in our innovative Remote office. This position requires a strong and diverse skillset in relevant areas to drive success. Earn a reliable and steady income of a competitive salary.

 

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Job Summary: 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 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 Compensation Range: $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 Apply Job!

 

We Encourage You to Apply!

Even if you feel you're not a perfect match, we'd still love to hear from you. We are looking for great people to join our friendly team.