RN Manager, Clinical Appeals

CareSource; Indiana; Hybrid; USD 83,000 - 133,000; Full time

Job summary

CareSource in Indiana seeks a Manager of Clinical Appeals to oversee all clinical appeals activities, ensuring compliant, timely decisions and alignment with state regulations. The role requires coordinating the appeals process, auditing outcomes, guiding staff, and partnering with providers to ensure appropriate benefits are applied and documented.

Strong leadership and data-driven decision making are essential for success.

Qualifications

• RN licensed in state of practice.
• 5+ years of clinical experience.
• 5+ years in utilization management, appeals, or quality improvement.
• 2+ years of leadership experience.
• Managed care leadership experience preferred.

Responsibilities

• Coordinate and manage the clinical appeals process.
• Ensure consistent application of criteria used during the clinical appeals process.
• Oversee data and processes to meet industry standards and timeframes.
• Interact with providers and staff to manage benefits per regulations.
• Review workflows to maximize efficiencies.
• Monitor productivity, turnaround time and volume trends.
• Oversee CQI activities, audits, and staff feedback.
• Ensure compliance with regulatory reporting requirements.
• Maintain all departmental policies and procedures.

Skills

Excel

Data analysis

Communication skills

Leadership

Education

Associate’s Degree in Nursing

Bachelor’s Degree in Nursing (BSN)

Tools

Word

PowerPoint

Job description

CareSource in Indiana seeks a Manager of Clinical Appeals to oversee all clinical appeals activities, ensuring compliant, timely decisions and alignment with state regulations. The role requires coordinating the appeals process, auditing outcomes, guiding staff, and partnering with providers to ensure appropriate benefits are applied and documented.

Strong leadership and data-driven decision making are essential for success.