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Seeking a Remote Clinical Appeals Nurse who will be responsible for the completion of clinical appeals and state hearings from all states (must have Ohio license).
Responsibilities:
• 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 hard copy 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.
Qualifications:
• Current, unrestricted RN License is required.
• Associate degree or equivalent years of relevant experience required.
• Managed care, appeals, and Medicaid experience preferred.
• Utilization review experience is strongly preferred.
• MCG Certification is required or must be obtained within six (6) months of hire.
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The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation options.
Other
$47k-57k (estimate)
05/02/2024
05/16/2024
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