Clinical Appeals Nurse
 Professional Management Enterprises | |
 United States, Ohio, Dayton | |
 May 07, 2024 | |
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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. | |