CareSource
Join to apply for the
Clinical Appeals Nurse - R9749
role at
CareSource 14 hours ago Be among the first 25 applicants Join to apply for the
Clinical Appeals Nurse - R9749
role at
CareSource Get AI-powered advice on this job and more exclusive features. Job Summary
The Clinical Appeals Nurse is responsible for processing clinical appeals and attending state hearings within compliance and regulatory standards, clinical guidelines, and contractual obligations. Job Summary
The Clinical Appeals Nurse is responsible for processing clinical appeals and attending state hearings within compliance and regulatory standards, clinical guidelines, and contractual obligations.
Essential Functions
Responsible for the completion of clinical appeals and state hearings from all states Perform 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 make informed decisions Document clinical rationale clearly and accurately in alignment with organizational and regulatory standards Work closely with medical directors, and pharmacists to resolve complex cases. Communicate outcomes effectively to members, and providers. Review and complete all provider clinical appeals within required timeframes Review and complete member clinical appeals within required timeframes Communicate with state agencies and internal departments to prepare for State Hearings Apply CareSource Medical Policy and Milliman guidelines when 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 all requests for Independent External Review Participate in training programs to maintain clinical and regulatory expertise. Perform any other job duties as requested
Education And Experience
Associate’s Degree required Managed care, appeals, Medicare, and Medicaid experience preferred Prior clinical appeals, and/or 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 clinical judgment Attention to detail Ability to navigate complex regulations while maintaining a commitment to high-quality care 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 Knowledge of Medicaid, and Medicare, Flexibility Change resiliency
Licensure And Certification
Current, unrestricted license as a Registered Nurse (RN) is required Multi-state RN license is preferred 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 Position requires the flexibility to work weekends, evenings, and/or holidays, as needed
Compensation Range
$61,500.00 - $98,400.00 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
Competencies
Create an Inclusive Environment - 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 inclusive environment that welcomes and supports individuals of all backgrounds.
Seniority level
Seniority level Entry level Employment type
Employment type Full-time Job function
Job function Health Care Provider Industries Insurance Referrals increase your chances of interviewing at CareSource by 2x Sign in to set job alerts for “Registered Nurse” roles.
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Clinical Appeals Nurse - R9749
role at
CareSource 14 hours ago Be among the first 25 applicants Join to apply for the
Clinical Appeals Nurse - R9749
role at
CareSource Get AI-powered advice on this job and more exclusive features. Job Summary
The Clinical Appeals Nurse is responsible for processing clinical appeals and attending state hearings within compliance and regulatory standards, clinical guidelines, and contractual obligations. Job Summary
The Clinical Appeals Nurse is responsible for processing clinical appeals and attending state hearings within compliance and regulatory standards, clinical guidelines, and contractual obligations.
Essential Functions
Responsible for the completion of clinical appeals and state hearings from all states Perform 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 make informed decisions Document clinical rationale clearly and accurately in alignment with organizational and regulatory standards Work closely with medical directors, and pharmacists to resolve complex cases. Communicate outcomes effectively to members, and providers. Review and complete all provider clinical appeals within required timeframes Review and complete member clinical appeals within required timeframes Communicate with state agencies and internal departments to prepare for State Hearings Apply CareSource Medical Policy and Milliman guidelines when 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 all requests for Independent External Review Participate in training programs to maintain clinical and regulatory expertise. Perform any other job duties as requested
Education And Experience
Associate’s Degree required Managed care, appeals, Medicare, and Medicaid experience preferred Prior clinical appeals, and/or 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 clinical judgment Attention to detail Ability to navigate complex regulations while maintaining a commitment to high-quality care 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 Knowledge of Medicaid, and Medicare, Flexibility Change resiliency
Licensure And Certification
Current, unrestricted license as a Registered Nurse (RN) is required Multi-state RN license is preferred 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 Position requires the flexibility to work weekends, evenings, and/or holidays, as needed
Compensation Range
$61,500.00 - $98,400.00 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
Competencies
Create an Inclusive Environment - 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 inclusive environment that welcomes and supports individuals of all backgrounds.
Seniority level
Seniority level Entry level Employment type
Employment type Full-time Job function
Job function Health Care Provider Industries Insurance Referrals increase your chances of interviewing at CareSource by 2x Sign in to set job alerts for “Registered Nurse” roles.
Registered Nurse (RN) Openings in NV - New Grads Welcome!
Nevada, United States $61,500.00-$98,400.00 14 hours ago Las Vegas, NV $64,680.00-$119,530.00 2 weeks ago Henderson, NV $64,680.00-$119,530.00 3 months ago Registered Nurse - Quality Assurance Coordinator
Las Vegas, NV $64,680.00-$119,530.00 2 weeks ago Registered Nurse (RN) Openings in NV - New Grads Welcome!
Las Vegas, NV $64,680.00-$119,530.00 1 week ago staff - Registered Nurse - Correctional - $43-55 per hour
staff - Registered Nurse - Correctional - $43-55 per hour
Las Vegas, NV $78,678.61-$132,686.16 2 weeks ago Pediatric Homecare Registered Nurse (RN) - $2000 Bonus
Special Procedures Nurse RN - full time days
We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
#J-18808-Ljbffr