Senior Clinical Appeals Manager & Quality Lead

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

Job summary

CareSource is seeking a Manager, Clinical Appeals to oversee all clinical appeals activities, ensuring consistency of services and achievement of compliance targets.

You will coordinate the appeals process, apply criteria consistently, monitor productivity and turnaround times, and lead CQI activities. You will interact with providers and staff, report regulatory requirements, and maintain all adverse action notices and trend data to improve member care.

Qualifications

• Associate's Degree in Nursing is required; BSN preferred.
• Bachelor of Science in Nursing (BSN) is preferred.
• Current, unrestricted RN licensure is required.
• MCG Certification is required or must be obtained within six months of hire.
• Minimum of five years of clinical experience in utilization management, appeals, or quality improvement.
• Two years of utilization management or appeals experience is preferred.
• Minimum of two years of leadership experience is preferred.

Responsibilities

• Coordinate and manage 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.

Skills

Data analysis

Communication

Leadership

Time management

Attention to detail

Customer service oriented

Negotiation

Strategic management

Training/teaching skills

Education

Associate’s Degree in Nursing

Bachelor of Science in Nursing (BSN)

MCG Certification

Tools

Excel

Word

PowerPoint

Job description

CareSource is seeking a Manager, Clinical Appeals to oversee all clinical appeals activities, ensuring consistency of services and achievement of compliance targets.

You will coordinate the appeals process, apply criteria consistently, monitor productivity and turnaround times, and lead CQI activities. You will interact with providers and staff, report regulatory requirements, and maintain all adverse action notices and trend data to improve member care.