Clinical Appeals Nurse

2 weeks ago

Dubai, Dubai, United Arab Emirates Actalent Full time

Responsible for the completion of clinical appeals and state hearings from all states
Review and complete all provider clinical appeals within required timeframes.
Review and complete member clinical appeals within required timeframes.
Review all information necessary to prepare State Hearing packets.
Communicate with state agencies and internal departments to prepare for State Hearings
Attend assigned State Hearing and completed all required compliances.
Complete required compliances for Administrative Hearing decisions
Apply CareSource Medical Policy and Milliman guidelines when processing clinical appeals.
Issue notification letters to providers and members.
Issue administrative denials appropriately.
Refer denials based on medical necessity to medical director.
Maintain hardcopy documentation, Facets documentation and appeals database documentation at 90-95% accuracy rates.
Conduct monthly, quarterly, and ad hoc appeals reporting.
Collaborate with the Quality Improvement and Clinical Operations Team Lead to prepare all requests for Independent External Review
Ensure compliance with regulatory and accrediting requirements.
Perform any other job duties as requested.

Additional Skills & Qualifications:

Current, unrestricted RN License is required.
Associate degree or equivalent years of relevant experience required.
Managed care, appeals, and Medicaid experience preferred.
Utilization review experience is strongly preferred.
MCG Certification is required or must be obtained within six (6) months of hire.

About Actalent

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

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Data collected and processed: Device identifiers, Non-precise location data, Probabilistic identifiers, Browsing and interaction data, Users' profiles, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Precise location data, Non-precise location data, Probabilistic identifiers, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices, Authentication-derived identifiers

Data collected and processed: Device identifiers, Precise location data, Non-precise location data, Device characteristics, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Non-precise location data, Probabilistic identifiers, User-provided data, Device characteristics, Browsing and interaction data, Users' profiles, IP addresses, Privacy choices, Authentication-derived identifiers

Data collected and processed: Non-precise location data, Device characteristics, Browsing and interaction data, Users' profiles, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Non-precise location data, Probabilistic identifiers, Device characteristics, Users' profiles, IP addresses, Authentication-derived identifiers

Data collected and processed: Device identifiers, Non-precise location data, Device characteristics, Browsing and interaction data, Users' profiles, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Precise location data, Non-precise location data, Probabilistic identifiers, Device characteristics, Browsing and interaction data, Users' profiles, IP addresses, Privacy choices, Authentication-derived identifiers

Data collected and processed: Device characteristics, Browsing and interaction data, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Non-precise location data, Probabilistic identifiers, Device characteristics, Browsing and interaction data, Users' profiles, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Non-precise location data, Probabilistic identifiers, User-provided data, Browsing and interaction data, IP addresses

Data collected and processed: Device identifiers, Precise location data, Non-precise location data, Device characteristics, Browsing and interaction data, Users' profiles, IP addresses, Privacy choices, Authentication-derived identifiers

Data collected and processed: Device identifiers, Non-precise location data, Probabilistic identifiers, Device characteristics, Users' profiles, IP addresses, Privacy choices

Data collected and processed: Non-precise location data, Probabilistic identifiers, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Precise location data, Non-precise location data, Probabilistic identifiers, User-provided data, Device characteristics, Browsing and interaction data, Users' profiles, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Precise location data, Non-precise location data, Probabilistic identifiers, Device characteristics, Browsing and interaction data, Users' profiles, IP addresses, Privacy choices, Authentication-derived identifiers

Data collected and processed: Device identifiers, Non-precise location data, User-provided data, Device characteristics, Browsing and interaction data, Users' profiles, IP addresses, Privacy choices, Authentication-derived identifiers

Data collected and processed: Device identifiers, Precise location data, Non-precise location data, Device characteristics, IP addresses

Data collected and processed: Non-precise location data, Device characteristics, Browsing and interaction data, IP addresses

Data collected and processed: Device identifiers, Non-precise location data, Device characteristics, Browsing and interaction data, Users' profiles, IP addresses, Privacy choices, Authentication-derived identifiers

Data collected and processed: Device identifiers, Non-precise location data, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Precise location data, Non-precise location data, User-provided data, Device characteristics, Browsing and interaction data, Users' profiles, IP addresses, Privacy choices

Data collected and processed: Non-precise location data, Device characteristics, Browsing and interaction data

Data collected and processed: Device identifiers, Precise location data, IP addresses

Data collected and processed: Device identifiers, Probabilistic identifiers, User-provided data, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices, Authentication-derived identifiers

Data collected and processed: Device identifiers, Device characteristics, IP addresses

Data collected and processed: Device identifiers, Browsing and interaction data, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Non-precise location data, Probabilistic identifiers, Device characteristics, Browsing and interaction data, IP addresses

Data collected and processed: Device identifiers, Probabilistic identifiers, User-provided data, Device characteristics, Browsing and interaction data, Users' profiles, IP addresses, Privacy choices, Authentication-derived identifiers

Data collected and processed: Device identifiers, Non-precise location data, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices, Authentication-derived identifiers

Data collected and processed: Device identifiers, Precise location data, Non-precise location data, Device characteristics, IP addresses, Privacy choices

Data collected and processed: Non-precise location data, Probabilistic identifiers, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Non-precise location data, User-provided data, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices, Authentication-derived identifiers

Data collected and processed: Device identifiers, Non-precise location data, User-provided data, Device characteristics, Browsing and interaction data, Users' profiles, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Non-precise location data, Device characteristics, Browsing and interaction data, Users' profiles, IP addresses, Privacy choices

Data collected and processed: Non-precise location data, Browsing and interaction data, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Non-precise location data, Probabilistic identifiers, User-provided data, Device characteristics, Users' profiles, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Non-precise location data, Device characteristics, Browsing and interaction data, Users' profiles, IP addresses, Authentication-derived identifiers

Data collected and processed: Device identifiers, Non-precise location data, Device characteristics, Browsing and interaction data, IP addresses

Data collected and processed: Device identifiers

Data collected and processed: Users' profiles

Data collected and processed: Device identifiers, Non-precise location data, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices

Data collected and processed: IP addresses

Data collected and processed: Device identifiers, IP addresses, Privacy choices, Authentication-derived identifiers

Data collected and processed: Non-precise location data, Device characteristics, IP addresses, Privacy choices

Integral Ad Science (incorporating ADmantX)

Data collected and processed: Non-precise location data, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices

Data collected and processed: Non-precise location data, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices, Authentication-derived identifiers

Data collected and processed: Device identifiers, Precise location data, Non-precise location data, Browsing and interaction data, Users' profiles, IP addresses, Privacy choices

Data collected and processed: Non-precise location data

Data collected and processed: Device identifiers, Precise location data, Non-precise location data, User-provided data, Device characteristics, Browsing and interaction data, IP addresses

Data collected and processed: Non-precise location data, Device characteristics, Browsing and interaction data, IP addresses

Data collected and processed: Device identifiers, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices, Authentication-derived identifiers

Data collected and processed: Device identifiers, Precise location data, Device characteristics, IP addresses

Data collected and processed: Device identifiers, Non-precise location data, User-provided data, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Device characteristics, Browsing and interaction data, Users' profiles, Privacy choices

Data collected and processed: Device identifiers, Non-precise location data, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Non-precise location data, Device characteristics, Browsing and interaction data, IP addresses

Data collected and processed: Device characteristics

Data collected and processed: Non-precise location data, IP addresses

Data collected and processed: Device characteristics, IP addresses

Data collected and processed: Device identifiers, IP addresses

Data collected and processed: Device identifiers, Precise location data, Non-precise location data, Probabilistic identifiers, Device characteristics, Browsing and interaction data, Users' profiles, IP addresses, Authentication-derived identifiers

Data collected and processed: Device identifiers, Non-precise location data, Probabilistic identifiers, Device characteristics, IP addresses

Data collected and processed: Device characteristics

Data collected and processed: Device identifiers, Non-precise location data, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices

Data collected and processed: Device characteristics

Data collected and processed: Device identifiers, User-provided data, Browsing and interaction data, Users' profiles, IP addresses, Privacy choices

Adobe Audience Manager, Adobe Experience Platform

Data collected and processed: Device identifiers, Precise location data, Non-precise location data, Device characteristics, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Probabilistic identifiers, User-provided data, Device characteristics, Browsing and interaction data, Users' profiles, IP addresses, Privacy choices

Data collected and processed: Non-precise location data, User-provided data, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Probabilistic identifiers, Device characteristics, Browsing and interaction data, Users' profiles, IP addresses

Data collected and processed: Device identifiers, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Non-precise location data, Users' profiles, IP addresses, Privacy choices

Data collected and processed: Device identifiers, Probabilistic identifiers, Device characteristics, Browsing and interaction data, IP addresses

Data collected and processed: Non-precise location data, IP addresses

Data collected and processed: IP addresses

Data collected and processed: Device identifiers, Non-precise location data, Device characteristics, IP addresses

Data collected and processed: Device identifiers, Non-precise location data, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices, Authentication-derived identifiers

Data collected and processed: Device identifiers

Data collected and processed: Device identifiers, Device characteristics, Browsing and interaction data, IP addresses, Privacy choices

Data collected and processed: Device characteristics, IP addresses, Privacy choices

Marketing Science Consulting Group, Inc.
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Clinical Appeals Nurse