Manager, Clinical Appeals

This is a fully remote position, open to applicants in United States.

📋 Description

• Coordinate and oversee the clinical appeals process associated with adverse benefit determinations.

• Ensure the consistent application of clinical appeals criteria.

• Manage clinical appeals data and processes, ensuring decisions are made within allowable timeframes.

• Collaborate with providers and staff to administer benefits in accordance with state regulations, NCQA, and CareSource policies.

• Review and refine workflows to enhance efficiencies.

• Monitor productivity, turnaround times, and volume trends.

• Supervise CQI activities, conduct audits, and provide regular feedback to staff.

• Report on clinical appeals regulatory requirements while maintaining accurate reporting and trend data.

• Analyze data related to utilization, state hearings, non-formulary exceptions, and outcomes from external and Independent Review Entities.

• Develop, maintain, and update departmental policies and procedures.

• Ensure that notices of adverse action are issued in compliance with regulations.

• Audit clinical appeal cases for documentation accuracy and interrater reliability.

• Collaborate with other departments for research and intervention purposes.

⛳️ Requirements

• An Associate’s Degree in Nursing is mandatory; a Bachelor of Science in Nursing (BSN) is preferred.

• A minimum of five (5) years of clinical experience is required.

• At least five (5) years of experience in utilization management, appeals, and/or quality improvement is necessary.

• Current, unrestricted licensure as a Registered Nurse (RN) in the state of practice is required.

• MCG Certification is required or must be acquired within six (6) months of hire.

• Basic experience with Excel, Word, and PowerPoint is needed.

• Proficiency in data analysis and trending is essential.

• Familiarity with utilization management standards and practices is necessary.

• Management and prior supervisory experience are required.

• Ability to work independently as well as collaboratively within a team environment.

• Knowledge of the healthcare industry is important.

• Strong critical listening and thinking skills are crucial.

• Training and teaching abilities are beneficial.

• Skills in strategic management are required.

• Experience with negotiation is preferred.

• Technical writing skills are necessary.

• Leadership experience and skills are essential.

🏝️ Benefits

• Bonus opportunities based on company and individual performance may be available.

• A substantial and comprehensive total rewards package is offered.

• Flexible remote work arrangements are available.