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.

Diversity, Equity & Inclusion

At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:

Maintaining an inclusive environment through persistent self-reflection
Building a culture of care, engagement, and recognition with clear outcomes
Ensuring growth opportunities for our people

Disclaimer: Drjobs.ae is only a platform that connects job seekers and employers. Applicants are advised to conduct their own independent research into the credentials of the prospective employer.We always make certain that our clients do not endorse any request for money payments, thus we advise against sharing any personal or bank-related information with any third party. If you suspect fraud or malpractice, please contact us via contact us page.

Dr. Job is an online platform that connects employers with skilled job seekers, facilitating the search for job opportunities and top talent. Established in 2015. Dr. Job has emerged as the UAE premier job portal, attracting thousands of job seekers every day in UAE.

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perm_identity Personalised advertising and content, advertising and content measurement, audience research and services development

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devices Store and/or access information on a device

Data preferences

You can choose how your personal data is used. Vendors want your permission to do the following:

Store and/or access information on a device

Advertising presented to you on this service can be based on limited data, such as the website or app you are using, your non-precise location, your device type or which content you are (or have been) interacting with (for example, to limit the number of times an ad is presented to you).

Create profiles for personalised advertising

Information about your activity on this service (such as forms you submit, content you look at) can be stored and combined with other information about you (for example, information from your previous activity on this service and other websites or apps) or similar users. This is then used to build or improve a profile about you (that might include possible interests and personal aspects). Your profile can be used (also later) to present advertising that appears more relevant based on your possible interests by this and other entities.

Use profiles to select personalised advertising

Advertising presented to you on this service can be based on your advertising profiles, which can reflect your activity on this service or other websites or apps (like the forms you submit, content you look at), possible interests and personal aspects.

Information about your activity on this service (for instance, forms you submit, non-advertising content you look at) can be stored and combined with other information about you (such as your previous activity on this service or other websites or apps) or similar users. This is then used to build or improve a profile about you (which might for example include possible interests and personal aspects). Your profile can be used (also later) to present content that appears more relevant based on your possible interests, such as by adapting the order in which content is shown to you, so that it is even easier for you to find content that matches your interests.

Use profiles to select personalised content

Content presented to you on this service can be based on your content personalisation profiles, which can reflect your activity on this or other services (for instance, the forms you submit, content you look at), possible interests and personal aspects. This can for example be used to adapt the order in which content is shown to you, so that it is even easier for you to find (non-advertising) content that matches your interests.

Information regarding which advertising is presented to you and how you interact with it can be used to determine how well an advert has worked for you or other users and whether the goals of the advertising were reached. For instance, whether you saw an ad, whether you clicked on it, whether it led you to buy a product or visit a website, etc. This is very helpful to understand the relevance of advertising campaigns.

Measure content performance

Information regarding which content is presented to you and how you interact with it can be used to determine whether the (non-advertising) content e.g. reached its intended audience and matched your interests. For instance, whether you read an article, watch a video, listen to a podcast or look at a product description, how long you spent on this service and the web pages you visit etc. This is very helpful to understand the relevance of (non-advertising) content that is shown to you.

Understand audiences through statistics or combinations of data from different sources

Reports can be generated based on the combination of data sets (like user profiles, statistics, market research, analytics data) regarding your interactions and those of other users with advertising or (non-advertising) content to identify common characteristics (for instance, to determine which target audiences are more receptive to an ad campaign or to certain contents).

Develop and improve services

Information about your activity on this service, such as your interaction with ads or content, can be very helpful to improve products and services and to build new products and services based on user interactions, the type of audience, etc. This specific purpose does not include the development or improvement of user profiles and identifiers.

Use limited data to select content

Content presented to you on this service can be based on limited data, such as the website or app you are using, your non-precise location, your device type, or which content you are (or have been) interacting with (for example, to limit the number of times a video or an article is presented to you).

Ensure security, prevent and detect fraud, and fix errors

Your data can be used to monitor for and prevent unusual and possibly fraudulent activity (for example, regarding advertising, ad clicks by bots), and ensure systems and processes work properly and securely. It can also be used to correct any problems you, the publisher or the advertiser may encounter in the delivery of content and ads and in your interaction with them.

Deliver and present advertising and content

Certain information (like an IP address or device capabilities) is used to ensure the technical compatibility of the content or advertising, and to facilitate the transmission of the content or ad to your device.

Match and combine data from other data sources

Information about your activity on this service may be matched and combined with other information relating to you and originating from various sources (for instance your activity on a separate online service, your use of a loyalty card in-store, or your answers to a survey), in support of the purposes explained in this notice.

In support of the purposes explained in this notice, your device might be considered as likely linked to other devices that belong to you or your household (for instance because you are logged in to the same service on both your phone and your computer, or because you may use the same Internet connection on both devices).

Identify devices based on information transmitted automatically

With your acceptance, your precise location (within a radius of less than 500 metres) may be used in support of the purposes explained in this notice.

Vendors can use your data to provide services. Declining a vendor can stop them from using the data you shared.

Exponential Interactive, Inc d/b/a VDX.tv

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, 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: 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

Clinical Appeals Nurse