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CareSource

Manager, Clinical Appeals

Place: Indiana WFH
Pay: $83k to $133k
Posted: Yesterday

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Applies on caresource.wd1.myworkdayjobs.com

The role

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 determinations

Ensure the consistent application of criteria used during the clinical appeals process

Oversee clinical appeals data and processes to maintain industry standards and practices including decisions within allowable timeframes

Interact with providers and staff to manage benefits aligned with state-based regulations, NCQA and CareSource policies

Review and revise workflows to maximize efficiencies

Monitor productivity, turnaround time and volume trends

Oversee CQI activities and ensure audits and staff feedback occur at regular intervals

Regularly report all clinical appeals regulatory requirements

Ensure compliance with and reporting of all regulatory requirements

Maintain all clinical appeals reporting and trend data

Analyze under and over utilization information for impact on member quality of care and outcomes and formulate recommendations based on data

Analyze state hearing, non-formulary exception, external and Independent Review Entity outcome data and formulate recommendations based on findings

Develop, maintain and update all departmental policies and procedures; ensure notices of adverse action are provided in accordance with required regulations

Audit clinical appeal cases for documentation and interrater reliability per CareSource policy

Act as liaison with other departments to assist with research and intervention

Perform 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 preferred

Minimum of five (5) years of clinical experience is required

Minimum of five (5) years of experience in one of the following is required: utilization management, appeals, and/or quality improvement

Two years of utilization management or appeals experience is preferred

Minimum of (2) years of leadership experience is preferred

Managed care leadership experience is preferred

Competencies, Knowledge and Skills:

Beginning Excel, Word and PowerPoint experience

Experience in data analysis and trending

Knowledge of utilization management standards and practices

Communication skills

Management and prior supervisory skills

Ability to work independently and within a team environment

Attention to detail

Familiarity of the health care field

Critical listening and thinking skills

Training/teaching skills

Strategic management skills

Negotiation skills/experience

Proper grammar usage

Change resiliency

Technical writing skills

Time management skills

Proper phone etiquette

Customer service oriented

Decision making/problem solving skills

Leadership 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

Compensation Range:

$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.

Compensation Type (hourly/salary):

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.

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Brand=CareSource