RN Clinical Appeals Manager | Utilization & Compliance

CareSource; United States; A distancia; USD 83.000 - 133.000; Jornada completa

Descripción de la vacante

CareSource is seeking a Manager, Clinical Appeals to oversee the end-to-end clinical appeals workflow, ensuring compliant and timely decisions. You will coordinate cases, monitor performance metrics, and lead CQI activities while collaborating with providers and internal teams.

The role requires an RN license, 5+ years in clinical settings with utilization management or appeals experience, and leadership capability. A BSN is preferred; office-based, salary position.

Formación

• RN licensure with current, unrestricted status is required.
• Bachelors of Science in Nursing preferred.
• Experience in utilization management, appeals or quality improvement is required.
• Leadership and supervisory experience is preferred.

Responsabilidades

• Oversee clinical appeals activities to ensure consistency and compliance.
• Coordinate and manage adverse benefit determinations and related processes.
• Monitor data, trends and regulatory reporting for CQI and audits.
• Interact with providers and staff to align benefits with regulations and policies.
• Develop, revise and maintain departmental policies and procedures.
• Audit cases for documentation quality and interrater reliability.
• Lead cross-functional collaboration and drive process improvements.

Conocimientos

Excel

Word

PowerPoint

Data analysis

Communication

Leadership

Time management

Attention to detail

Educación

Associate’s Degree in Nursing

BSN preferred

Descripción del empleo

CareSource is seeking a Manager, Clinical Appeals to oversee the end-to-end clinical appeals workflow, ensuring compliant and timely decisions. You will coordinate cases, monitor performance metrics, and lead CQI activities while collaborating with providers and internal teams.

The role requires an RN license, 5+ years in clinical settings with utilization management or appeals experience, and leadership capability. A BSN is preferred; office-based, salary position.