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

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

Originally posted on