Clinical Appeals Nurse

3 weeks ago


Indianapolis, United States aFit Staffing Inc. Full time
Job DescriptionJob Description

More about aFit:

You want to work where you know you are a perfect fit. At aFit, a woman owned (WBE) company based in Indianapolis, we are devoted to being collaborative, honorable, and accountable. Our company provides project-based staffing for government and commercial organizations. To our prospective clients, aFit offers a talented workforce in a team-based environment to produce concrete and reliable outcomes. At aFit, we focus on building strong relationships and keeping the day-to-day flexible in an in-person or remote-enabled environment.

aFit Staffing, Inc. is an equal opportunity employer.

Description of Duties:

The Clinical Appeals Nurse is responsible for the completion of clinical appeals and state hearings from all states.

*Ohio License Is Required


Essential Functions:

  • Responsible for the completion of clinical appeals and state hearings from all states
  • Review and complete all provider clinical appeals within required timeframes.
  • Review and complete member clinical appeals within required timeframes.
  • Review all information necessary to prepare State Hearing packets.
  • Communicate with state agencies and internal departments to prepare for State Hearings
  • Attend assigned State Hearing and completed all required compliances.
  • Complete required compliances for Administrative Hearing decisions
  • Apply CareSource Medical Policy and Milliman guidelines when processing clinical appeals.
  • Issue notification letters to providers and members.
  • Issue administrative denials appropriately.
  • Refer denials based on medical necessity to medical director.
  • Maintain hardcopy documentation, Facets documentation and appeals database documentation at 90-95% accuracy rates.
  • Conduct monthly, quarterly, and ad hoc appeals reporting.
  • Collaborate with the Quality Improvement and Clinical Operations Team Lead to prepare all requests for Independent External Review
  • Ensure compliance with regulatory and accrediting requirements.
  • Perform any other job duties as requested.

Education and Experience:

  • RN License required.
  • Associate degree or equivalent years of relevant experience required.
  • Managed care, appeals, and Medicaid experience preferred.
  • Utilization review experience is strongly preferred.

Competencies, Knowledge, and Skills:

  • Intermediate proficiency with Microsoft Office products and Facets
  • Knowledge of NCQA, URAC, OAC, and MDCH regulations
  • Strong written and oral communication skills
  • Ability to work independently and within a team environment.
  • Critical listening and thinking skills.
  • Proper grammar usage
  • Time management skills
  • Proper phone etiquette
  • Customer Service oriented
  • Decision making/problem solving skills.
  • Familiarity of healthcare field
  • Knowledge of Medicaid
  • Flexibility
  • Change resiliency.

Licensure and Certification:

  • Current, unrestricted license as a Registered Nurse (RN) is required.
  • MCG Certification is required or must be obtained within six (6) months of hire.

Please note, this full-time remote position and we do not offer relocation assistance at this time.


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