Clinical Appeals Nurse

Description:

• 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.
  

Additional Skills & Qualifications:

• Current, unrestricted RN License is required.
• Associate degree or equivalent years of relevant experience required.
• Managed care, appeals, and Medicaid experience preferred.
• Utilization review experience is strongly preferred.
• MCG Certification is required or must be obtained within six (6) months of hire.
  

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

Diversity, Equity & Inclusion

At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:

• Hiring diverse talent
• Maintaining an inclusive environment through persistent self-reflection
• Building a culture of care, engagement, and recognition with clear outcomes
• Ensuring growth opportunities for our people