Manager, Clinical Appeals

🔥 12 hours ago

🇺🇸 United States – Remote

💵 $83k - $132.8k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Coordinate and manage the clinical appeals process related to adverse benefit determinations • Ensure consistent application of clinical appeals criteria • Oversee clinical appeals data and processes, including decisions within allowable timeframes • Interact with providers and staff to manage benefits aligned with state regulations, NCQA and CareSource policies • Review and revise workflows to maximize efficiencies • Monitor productivity, turnaround time and volume trends • Oversee CQI activities, audits and regular staff feedback • Report clinical appeals regulatory requirements and maintain reporting and trend data • Analyze utilization, state hearing, non-formulary exception, external and Independent Review Entity outcome data • Develop, maintain and update departmental policies and procedures • Ensure notices of adverse action are provided according to regulations • Audit clinical appeal cases for documentation and interrater reliability • Liaise with other departments for research and intervention

🎯 Requirements

• Associate’s Degree in Nursing is required; Bachelor of Science in Nursing (BSN) preferred • Minimum of five (5) years of clinical experience required • Minimum of five (5) years of experience in utilization management, appeals, and/or quality improvement required • Current, unrestricted licensure in state of practice as a Registered Nurse (RN) required • MCG Certification required or must be obtained within six (6) months of hire • Beginning Excel, Word and PowerPoint experience • Experience in data analysis and trending • Knowledge of utilization management standards and practices • Management and prior supervisory skills • Ability to work independently and within a team environment • Familiarity with the health care field • Critical listening and thinking skills • Training/teaching skills • Strategic management skills • Negotiation skills/experience • Technical writing skills • Leadership experience and skills

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Substantial and comprehensive total rewards package • Remote work arrangement