Manager, Clinical Appeals

Job Summary

The Manager, Clinical Appeals is responsible for the oversight of all clinical appeals activities ensuring consistency of services and achievement of compliance targets.

Essential Functions

• Assist in coordination and management of 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

Education and Experience

• Associate’s Degree in Nursing is required and Bachelors of Science in Nursing (BSN) is preferred
• Minimum of five (5) years of clinical experience is required
• Minimum of five (5) years of experience in one of the following is required: utilization management, appeals, and/or quality improvement
• 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 of the health care 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 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