Clinical Appeals Manager: Compliance & Quality Lead

CareSource; Butlerville (IN); On-site; USD 83,000 - 133,000; Full time

Job summary

CareSource is seeking a Manager of Clinical Appeals to oversee the end-to-end clinical appeals process ensuring consistent application of criteria and adherence to compliance targets.

The role requires a Registered Nurse with five years of clinical experience and leadership exposure, plus familiarity with utilization management, appeals, and quality improvement. Strong data skills and regulatory reporting are essential.

Qualifications

• RN with current, unrestricted licensure in state of practice as a Registered Nurse (RN).
• Associate’s Degree in Nursing is required and BSN is preferred.
• Minimum of five (5) years of clinical experience is required.
• Minimum of five (5) years of experience in utilization management, appeals, and/or quality improvement.
• Two years of utilization management or appeals experience is preferred.
• Minimum of two (2) years of leadership experience is preferred.

Responsibilities

• 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.

Skills

Excel

Communication skills

Attention to detail

Leadership

Time management

Education

Associate’s Degree in Nursing

BSN preferred

Tools

Word

PowerPoint

Job description

CareSource is seeking a Manager of Clinical Appeals to oversee the end-to-end clinical appeals process ensuring consistent application of criteria and adherence to compliance targets.

The role requires a Registered Nurse with five years of clinical experience and leadership exposure, plus familiarity with utilization management, appeals, and quality improvement. Strong data skills and regulatory reporting are essential.