Clinical Appeals Nurse

2 weeks ago


Dubai, Dubai, United Arab Emirates Actalent Full time

Description:

  • Responsible for the completion ofclinical appeals and state hearings from allstates
  • Review and complete all providerclinical appeals within requiredtimeframes.
  • Review and complete member clinicalappeals within required timeframes.
  • Review allinformation necessary to prepare State Hearingpackets.
  • Communicate with state agencies andinternal departments to prepare for StateHearings
  • Attend assigned State Hearing andcompleted all required compliances.
  • Completerequired compliances for Administrative Hearingdecisions
  • Apply CareSource Medical Policy andMilliman guidelines when processing clinicalappeals.
  • Issue notification letters toproviders and members.
  • Issue administrativedenials appropriately.
  • Refer denials based onmedical necessity to medical director.
  • Maintainhardcopy documentation, Facets documentation and appeals databasedocumentation at 90-95% accuracy rates.
  • Conductmonthly, quarterly, and ad hoc appealsreporting.
  • Collaborate with the QualityImprovement and Clinical Operations Team Lead to prepare allrequests for Independent External Review
  • Ensurecompliance with regulatory and accreditingrequirements.
  • Perform any other job duties asrequested.

Additional Skills& Qualifications:

  • Current, unrestricted RN License isrequired.
  • Associate degree or equivalent yearsof relevant experience required.
  • Managed care,appeals, and Medicaid experiencepreferred.
  • Utilization review experience isstrongly preferred.
  • MCG Certification isrequired or must be obtained within six (6) months ofhire.

AboutActalent

Actalent is a globalleader in engineering and sciences services and talent solutions.We help visionary companies advance their engineering and scienceinitiatives through access to specialized experts who drive scale,innovation and speed to market. With a network of almost 30,000consultants and more than 4,500 clients across the U.S., Canada,Asia and Europe, Actalent serves many of the Fortune500.

Diversity, Equity &Inclusion

At Actalent,diversity and inclusion are a bridge towards the equity and successof our people. DE&I are embedded into our culturethrough:

  • Hiring diversetalent
  • Maintaining an inclusive environmentthrough persistent self-reflection
  • Building aculture of care, engagement, and recognition with clearoutcomes
  • Ensuring growth opportunities for ourpeople


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