Clinical Appeals - R11356

Job Summary

The Clinical Appeals Nurse is responsible for processing clinical appeals and attending state hearings within compliance and regulatory standards, clinical guidelines, and contractual obligations.

• Responsible for the completion of clinical appeals and state hearings from all states
• Perform clinical reviews of member and provider appeals for medical, dental, behavioral health, pharmacy, and waiver services
• Analyze medical records, supporting documentation, and applicable guidelines to make informed decisions
• Document clinical rationale clearly and accurately in alignment with organizational and regulatory standards
• Work closely with medical directors and pharmacists to resolve complex cases
• Communicate outcomes effectively to members and providers
• Review and complete all provider clinical appeals within required time frames
• Review and complete member clinical appeals within required time frames
• Communicate with state agencies and internal departments to prepare for state hearings
• Apply Care Source Medical Policy and Milliman guidelines when processing clinical appeals
• Issue administrative denials appropriately
• Refer denials based on medical necessity to medical director
• Collaborate with the Quality Improvement and Clinical Operations teams to prepare all requests for independent external review
• Participate in training programs to maintain clinical and regulatory expertise
• Perform any other job duties as requested

• Associate’s Degree required
• Managed care, appeals, Medicare, and Medicaid experience preferred
• Prior clinical appeals and/or utilization review experience strongly preferred

• Intermediate proficiency with Microsoft Office products and Facets
• Knowledge of NCQA, URAC, OAC, and MDCH regulations
• Strong clinical judgment
• Attention to detail
• Ability to navigate complex regulations while maintaining a commitment to high‑quality care
• Strong written and oral communication skills
• Ability to work independently and within a team environment
• Critical listening and thinking skills
• Proper grammar usage
• Time management skills
• Proper phone etiquette
• Customer service orientation
• Decision‑making/problem‑solving skills
• Knowledge of Medicaid and Medicare
• Flexibility
• Change resiliency

• Current, unrestricted license as a Registered Nurse (RN) is required
• Multi‑state RN license is preferred
• MCG Certification required or to be obtained within six months of hire

• General office environment; may require sitting or standing for extended periods
• Position requires flexibility to work weekends, evenings, and/or holidays as needed

$62,700.00 – $. Compensation is based on education, training, and experience, as well as the role’s scope and complexity. In addition to base pay, a bonus tied to company and individual performance may be available. A comprehensive rewards package is also offered.

• Entry level

• Full‑time

• Health Care Provider
• Industry: Insurance

Care Source is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.