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Job Summary:
The Manager, Clinical Appeals is responsible for the oversight of all clinical appeals activities ensuring consistency of services and achievement of compliance targets.
Essential Functions:
Assist in coordination and management of the clinical appeals process related to adverse benefit determinations
Ensure the consistent application of criteria used during the clinical appeals process
Oversee clinical appeals data and processes to maintain industry standards and practices including decisions within allowable timeframes
Interact with providers and staff to manage benefits aligned with state-based regulations, NCQA and CareSource policies
Review and revise workflows to maximize efficiencies
Monitor productivity, turnaround time and volume trends
Oversee CQI activities and ensure audits and staff feedback occur at regular intervals
Regularly report all clinical appeals regulatory requirements
Ensure compliance with and reporting of all regulatory requirements
Maintain all clinical appeals reporting and trend data
Analyze under and over utilization information for impact on member quality of care and outcomes and formulate recommendations based on data
Analyze state hearing, non-formulary exception, external and Independent Review Entity outcome data and formulate recommendations based on findings
Develop, maintain and update all departmental policies and procedures; ensure notices of adverse action are provided in accordance with required regulations
Audit clinical appeal cases for documentation and interrater reliability per CareSource policy
Act as liaison with other departments to assist with research and intervention
Perform any other job related instructions, as requested
Education and Experience:
Associate’s Degree in Nursing is required and Bachelors of Science in Nursing (BSN) is preferred
Minimum of five (5) years of clinical experience is required
Minimum of five (5) years of experience in one of the following is required: utilization management, appeals, and/or quality improvement
Two years of utilization management or appeals experience is preferred
Minimum of (2) years of leadership experience is preferred
Managed care leadership experience is preferred
Competencies, Knowledge and Skills:
Beginning Excel, Word and PowerPoint experience
Experience in data analysis and trending
Knowledge of utilization management standards and practices
Communication skills
Management and prior supervisory skills
Ability to work independently and within a team environment
Attention to detail
Familiarity of the health care field
Critical listening and thinking skills
Training/teaching skills
Strategic management skills
Negotiation skills/experience
Proper grammar usage
Change resiliency
Technical writing skills
Time management skills
Proper phone etiquette
Customer service oriented
Decision making/problem solving skills
Leadership experience and skills
Licensure and Certification:
Current, unrestricted licensure in state of practice 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:
$83,000.00 - $132,800.00 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. In addition to base 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.
Compensation Type (hourly/salary):
Salary Organization Level Competencies
Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.