Job Summary: 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 complete 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 ? Associates 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 Compensation Range: $60,300.00 - $96,500.00 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. We are highly invested in every employee?s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type: Salary