Job description
The Clinical Appeals Nurse is responsible for processing clinical appeals and attending state hearings within compliance and regulatory standards, clinical guidelines, and contractual obligations.
Responsibilities
- Process Clinical Appeals & Hearings: Complete member and provider clinical appeals and prepare for state hearings within required timeframes and compliance standards.
Conduct Clinical Reviews: Evaluate medical, dental, behavioral health, pharmacy, and waiver service appeals using medical records, documentation, and guidelines.
What specific clinical reviews will they be reviewing?
Inpatient, outpatient, behavioral health, etc.
Apply Policies & Guidelines: Utilize CareSource Medical Policy and Milliman criteria; issue administrative denials and refer medical necessity cases to medical directors.
Collaborate & Communicate: Work with medical directors, pharmacists, and internal teams; communicate outcomes clearly to members, providers, and state agencies.
Documentation & Compliance: Maintain accurate clinical rationale and ensure adherence to regulatory and organizational standards.
Support Quality & External Reviews: Assist in preparing cases for Independent External Review and contribute to quality improvement initiatives.
Maintain Expertise: Participate in ongoing training to stay current with clinical and regulatory requirements.
About Insight Global
Insight Global is an international talent and consulting company that delivers business outcomes in an ever-changing world. We obsess over solving problems and building solutions that move our customers further, faster.
With access to top talent in more than 50 countries, our tech-enabled recruiters can build teams quickly. Our technical experts across Cloud, AI, Data, Enterprise Operations, and Applied Engineering deliver solutions tailored to each customer’s needs. As those needs evolve, so do we.
As we evolve, though, we stay true to our purpose: to develop people personally, professionally, and financially so they can be the light to the world around them. It shows up in everything we do, from investing in our people to delivering results for our customers to making a meaningful impact in our communities.
