About the Role
The Clinical Appeals Nurse is responsible for the completion of clinical appeals and state hearings from all states.
Essential Functions:
• 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
• Apply Company 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
Requirements
Education and Experience:
• RN License required
• Associates Degree or equivalent years of relevant experience required
• Managed care, appeals, and Medicaid experience preferred
• 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 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
Licensure and Certification:
• Current, unrestricted license as a Registered Nurse (RN) is required
• MCG Certification is required or must be obtained within six (6) months of hire
About the Company
RepuCare, a certified Woman Owned Business (WBE), is a leader in providing innovative workforce solutions. We have partnered with a large managed care provider seeking a skilled and dedicated Clinical Appeals Nurse to join their team.