- 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
- 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
- Associates Degree or equivalent years of relevant experience required
- Managed care, appeals, and Medicaid experience 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
Clinical Appeals Nurse - , OH, United States - Medasource
Description
Clinical Appeals Nurse (Remote)
Location: 100% Remote
Full-time
Start Date: ASAP
Essential Functions:
Education and Experience:
Competencies, Knowledge and Skills:
· Medasource provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, national origin, age, sex, citizenship, disability, genetic information, gender, sexual orientation, gender identity, marital status, amnesty or status as a covered veteran in accordance with applicable federal, state, and local laws.