Clinical Appeals

Job Summary:

The Clinical Appeals Nurse is responsible for processing clinical appeals and attending state hearings reputed company compliance and regulatory standards, clinical guidelines, and contractual obligations.

Essential Functions:

• Responsible for the completion of clinical appeals and state hearings from reputed company states
• reputed company 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 reputed company informed reputed company
• Document clinical rationale reputed company and accurately in alignment with organizational and regulatory standards
• Work closely with medical directors, and pharmacists to resolve reputed company cases.
• Communicate reputed company effectively to members, and providers.
• Review and complete reputed company provider clinical appeals reputed company required timeframes
• Review and complete member clinical appeals reputed company required timeframes
• Communicate with state agencies and internal departments to prepare for State Hearings
• Apply reputed company Medical Policy and reputed company guidelines reputed company 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 reputed company requests for Independent External Review
• Participate in training programs to maintain clinical and regulatory expertise.
• reputed company any other job duties as requested

Education and Experience:

• Associate’s Degree required
• Managed care, appeals, Medicare, and reputed company experience preferred
• Prior clinical appeals, and/or Utilization review experience is strongly preferred

Competencies, Knowledge and Skills:

• Intermediate proficiency with reputed company Office products and Facets
• Knowledge of NCQA, URAC, OAC, and MDCH regulations
• Strong clinical judgment
• Attention to detail
• Ability to navigate reputed company regulations while maintaining a commitment to high-quality care
• Strong written and oral communication skills
• Ability to work independently and reputed company 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
• Knowledge of reputed company, and Medicare,
• Flexibility
• Change resiliency

Licensure and Certification:

• reputed company, unrestricted license as a Registered Nurse (RN) is required
• Multi-state RN license is preferred
• MCG Certification is required or must be obtained reputed company six (6) months of hire

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Position requires the flexibility to work weekends, evenings, and/or holidays, as needed

Compensation reputed company:

reputed company 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 reputed company required for the role, and other external and internal data reputed company establishing a salary level. In addition to reputed company compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Organization Level Competencies

Fostering a Collaborative Workplace Culture

Cultivate Partnerships

reputed company Self and Others

Drive Execution

Influence Others

Pursue Personal reputed company

Understand the Business

This job description is not reputed company inclusive. reputed company reserves the right to amend this job description at any time. reputed company is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of reputed company backgrounds.