Manager, Clinical Appeals

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 determinationsEnsure the consistent application of criteria used during the clinical appeals processOversee clinical appeals data and processes to maintain industry standards and practices including decisions within allowable timeframesInteract with providers and staff to manage benefits aligned with state-based regulations, NCQA and CareSource policiesReview and revise workflows to maximize efficienciesMonitor productivity, turnaround time and volume trendsOversee CQI activities and ensure audits and staff feedback occur at regular intervalsRegularly report all clinical appeals regulatory requirementsEnsure compliance with and reporting of all regulatory requirementsMaintain all clinical appeals reporting and trend dataAnalyze under and over utilization information for impact on member quality of care and outcomes and formulate recommendations based on dataAnalyze state hearing, non-formulary exception, external and Independent Review Entity outcome data and formulate recommendations based on findingsDevelop, maintain and update all departmental policies and procedures; ensure notices of adverse action are provided in accordance with required regulationsAudit clinical appeal cases for documentation and interrater reliability per CareSource policyAct as liaison with other departments to assist with research and interventionPerform 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 preferredMinimum of five (5) years of clinical experience is requiredMinimum of five (5) years of experience in one of the following is required: utilization management, appeals, and/or quality improvementTwo years of utilization management or appeals experience is preferredMinimum of (2) years of leadership experience is preferredManaged care leadership experience is preferred Competencies, Knowledge And Skills Beginning Excel, Word and PowerPoint experienceExperience in data analysis and trendingKnowledge of utilization management standards and practicesCommunication skillsManagement and prior supervisory skillsAbility to work independently and within a team environmentAttention to detailFamiliarity of the health care fieldCritical listening and thinking skillsTraining/teaching skillsStrategic management skillsNegotiation skills/experienceProper grammar usageChange resiliencyTechnical writing skillsTime management skillsProper phone etiquetteCustomer service orientedDecision making/problem solving skillsLeadership 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 $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. 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.