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Clinical Appeals Manager

2 months ago

Dayton, Ohio, United States CareSource Full time
Job Summary:

The Clinical Appeals Manager is responsible for overseeing the clinical appeals process, ensuring consistency of services and achievement of compliance targets. This role requires strong leadership and management skills to coordinate and manage the clinical appeals process, ensuring timely and accurate decision-making.

Key Responsibilities:
  • Coordinate and manage the clinical appeals process, ensuring consistency and compliance with regulatory requirements.
  • Develop and implement policies and procedures to ensure efficient and effective clinical appeals management.
  • Oversee clinical appeals data and processes, ensuring industry standards and practices are maintained.
  • Interact with healthcare providers and staff to manage benefits aligned with state-based regulations, NCQA, and CareSource policies.
  • Review and revise workflows to maximize efficiencies and improve productivity.
  • Monitor productivity, turnaround time, and volume trends, making recommendations for improvement.
  • Oversee Continuous Quality Improvement (CQI) activities, ensuring regular audits and staff feedback.
  • Regularly report on clinical appeals regulatory requirements and ensure compliance.
  • Maintain all clinical appeals reporting and trend data, analyzing under and over utilization information for impact on member quality of care and outcomes.
  • Analyze state hearing, non-formulary exception, external, and Independent Review Entity outcome data, formulating recommendations based on findings.
  • Develop, maintain, and update all departmental policies and procedures, ensuring 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.
Requirements:
  • Associate's Degree in Nursing is required, with a Bachelor's of Science in Nursing (BSN) preferred.
  • Minimum of five (5) years of clinical experience is required.
  • Minimum of five (5) years of experience in utilization management, appeals, and/or quality improvement is required.
  • 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 with the healthcare field.
  • Critical listening and thinking skills.
  • Training/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 the 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.