Clinical Appeals Nurse

Overview

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

• Process Clinical Appeals & Hearings: Complete member and provider clinical appeals and prepare for state hearings within required time frames 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?
• Apply Policies & Guidelines: Utilize Care Source 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.

Volume = overall productivity is around 5 appeals per day. Outside of appeals, they will have admin tasks including create packets for hearing, creating packets for external reviews etc.