- 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 completed 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.
- RN License required.
- Associate degree or equivalent years of relevant experience required.
- Managed care, appeals, and Medicaid experience preferred.
- Utilization review experience is strongly preferred.
- 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.
- Current, unrestricted license as a Registered Nurse (RN) is required.
- MCG Certification is required or must be obtained within six (6) months of hire.
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Clinical Appeals Nurse - Indianapolis, United States - aFit Staffing Inc.
Description
More about aFit:
You want to work where you know you are a perfect fit. At aFit, a woman owned (WBE) company based in Indianapolis, we are devoted to being collaborative, honorable, and accountable. Our company provides project-based staffing for government and commercial organizations. To our prospective clients, aFit offers a talented workforce in a team-based environment to produce concrete and reliable outcomes. At aFit, we focus on building strong relationships and keeping the day-to-day flexible in an in-person or remote-enabled environment.
aFit Staffing, Inc. is an equal opportunity employer.
Description of Duties:
The Clinical Appeals Nurse is responsible for the completion of clinical appeals and state hearings from all states.
*Ohio License Is Required
Essential Functions:
Education and Experience:
Competencies, Knowledge, and Skills:
Licensure and Certification:
Please note, this full-time remote position and we do not offer relocation assistance at this time.
