Manager, Clinical Appeals

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

Benefits offered by this job

Bonus potential

Total rewards package

Job summary

CareSource in Indianapolis is seeking a Manager, Clinical Appeals to oversee all clinical appeals activities, ensuring consistency of services and compliance targets. The role manages adverse determinations, applies criteria consistently, analyzes utilization and CQI activities, and reports on regulatory requirements.

The ideal candidate has RN licensure, 5+ years of clinical and appeals or UM experience, and leadership experience, with proficiency in data analysis and common tools.

Qualifications

• Current, unrestricted RN license is required.
• Minimum 5 years of clinical experience.
• Minimum 5 years in utilization management, appeals, or quality improvement.
• 2 years of utilization management or appeals experience preferred.
• 2 years of leadership experience preferred.
• Managed care leadership experience preferred.

Responsibilities

• Oversee coordination of the clinical appeals process related to adverse determinations.
• Ensure consistent application of criteria used in clinical appeals.
• Manage clinical appeals data and processes to meet industry standards and timeframes.
• Interact with providers and staff to align benefits with state regulations and policies.
• Review and revise workflows to maximize efficiencies.
• Monitor productivity, turnaround time, and volume trends.
• Oversee CQI activities and audits with staff feedback.
• Regularly report regulatory requirements for clinical appeals.
• Maintain reporting and trend data for clinical appeals.
• Analyze utilization and outcomes data to improve member care.
• Develop and update departmental policies; issue notices of adverse action as required.
• Audit cases for documentation and interrater reliability.

Skills

Excel

Data analysis

Communication

Leadership

Time management

Education

Associate’s Degree in Nursing

BSN preferred

Tools

MS Office

Healthcare analytics

Job description

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 skillsTraining/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

Salary

$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.

Organization Level Competencies

• Fostering a Collaborative Workplace Culture
• Cultivate Partnerships
• Develop Self and Others
• Drive Execution
• Influence OthersPursue 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.