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.#LI-JS1
Brand=CareSource
