clinical appeals - r11356

clinical appeals r11356

CareSource

<div>
 
 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.
 
 
 
 Essential Functions
 
 
 
 <ul>
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 Responsible for the completion of clinical appeals and state hearings from all states
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 Perform clinical reviews of member and provider appeals for medical, dental, behavioral health, pharmacy, and waiver services
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 Analyze medical records, supporting documentation, and applicable guidelines to make informed decisions
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 Document clinical rationale clearly and accurately in alignment with organizational and regulatory standards
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 Work closely with medical directors, and pharmacists to resolve complex cases.
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 Communicate outcomes effectively to members, and providers.
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 Review and complete all provider clinical appeals within required timeframes
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 Review and complete member clinical appeals within required timeframes
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 <li>
 Communicate with state agencies and internal departments to prepare for State Hearings
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 Apply CareSource Medical Policy and Milliman guidelines when processing clinical appeals
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 Issue administrative denials appropriately
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 Refer denials based on medical necessity to medical director
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 Collaborate with the Quality Improvement and Clinical Operations teams to prepare all requests for Independent External Review
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 Participate in training programs to maintain clinical and regulatory expertise.
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 Perform any other job duties as requested
 
 
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 </ul>
 
 Education And Experience
 
 
 
 <ul>
 <li>
 Associate&rsquo;s Degree required
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 Managed care, appeals, Medicare, and Medicaid experience preferred
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 Prior clinical appeals, and/or Utilization review experience is strongly preferred
 
 
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 </ul>
 
 Competencies, Knowledge And Skills
 
 
 
 <ul>
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 Intermediate proficiency with Microsoft Office products and Facets
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 Knowledge of NCQA, URAC, OAC, and MDCH regulations
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 Strong clinical judgment
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 Attention to detail
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 Ability to navigate complex regulations while maintaining a commitment to high-quality care
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 Strong written and oral communication skills
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 Ability to work independently and within a team environment
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 Critical listening and thinking skills
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 Proper grammar usage
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 Time management skills
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 Proper phone etiquette
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 Customer Service oriented
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 Decision making/problem solving skills
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 Knowledge of Medicaid, and Medicare,
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 Flexibility
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 Change resiliency
 
 
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 </ul>
 
 Licensure And Certification
 
 
 
 <ul>
 <li>
 Current, unrestricted license as a Registered Nurse (RN) is required
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 Multi-state RN license is preferred
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 MCG Certification is required or must be obtained within six (6) months of hire
 
 
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 </ul>
 
 Working Conditions
 
 
 
 <ul>
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 General office environment; may be required to sit or stand for extended periods of time
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 Position requires the flexibility to work weekends, evenings, and/or holidays, as needed
 
 
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 </ul>
 
 Compensation Range
 
 
 
 $62,700.00 - $100,400.00 CareSource takes into consideration a combination of a candidate&rsquo;s education, training, and experience as well as the position&rsquo;s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee&rsquo;s total well-being and offer a substantial and comprehensive total rewards package.
 
 
 
 Compensation Type
 
 
 
 Hourly
 
 
 
 Competencies
 
 
 
 <ul>
 <li>
 Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business
 
 
 </li>
 </ul>
 This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
 
 
</div>

Clinical Appeals - R11356

Flexzo Ai

<div>
 
 
 About the Role
 
 
 
 We are seeking a
 
 licensed Pharmacist
 
 to provide safe, accurate, and patient-centered pharmacy services. This role includes dispensing medications, verifying prescriptions, counseling patients, collaborating with healthcare providers, and ensuring compliance with federal/state regulations and organizational policies. The ideal candidate brings strong clinical judgment, attention to detail, and a commitment to excellent patient care.
 
 
 
 
 
 
 Key Responsibilities
 
 
 <ul>
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 Review and verify prescriptions for accuracy, appropriateness, interactions, allergies, contraindications, and dosing
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 Dispense medications in compliance with state and federal laws, including controlled substances regulations
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 Provide patient counseling on medication use, side effects, storage, adherence, and drug interactions
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 Communicate with prescribers and clinical teams to clarify orders, recommend therapy changes, and resolve medication-related issues
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 Support medication therapy management (MTM), immunizations, and preventive care services where permitted
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 Oversee pharmacy technicians and support staff; ensure workflow efficiency and quality standards
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 Maintain accurate documentation, inventory management, and controlled substance reconciliation
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 Ensure compliance with pharmacy policies, safety standards, HIPAA, and accreditation requirements as applicable
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 Participate in quality improvement initiatives, audits, and continuous process enhancements
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 For clinical/hospital roles (as applicable): support antimicrobial stewardship, pharmacokinetics monitoring, formulary management, and clinical consults
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 </ul>
 
 
 
 
 
 Qualifications
 
 
 <ul>
 <li>
 PharmD (Doctor of Pharmacy) from an ACPE-accredited program (or equivalent)
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 <li>
 Active Pharmacist license in the practicing state (or eligibility to obtain)
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 <li>
 Strong knowledge of pharmacology, medication safety, and applicable regulations
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 Excellent communication and customer/patient service skills
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 Ability to work independently while collaborating in a team environment
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 Proficiency with pharmacy systems and electronic health records (EHR) as applicable
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 Ability to stand for extended periods and lift typical pharmacy inventory weights (role dependent)
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 </ul>
 
 
 
 
 
 Preferred
 
 
 <ul>
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 Residency training (PGY1/PGY2) for clinical/hospital/specialty roles
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 Board certification (e.g., BCPS) or immunization certification (where applicable)
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 Experience in retail, inpatient, ambulatory care, specialty pharmacy, compounding, or long-term care
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 Familiarity with insurance adjudication, prior authorizations, and specialty medication workflows
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 Bilingual proficiency aligned to patient population needs (e.g., Spanish)
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 </ul>
 
 
 
 
 
 Work Environment &amp; Schedule
 
 
 <ul>
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 Schedule varies by setting (days/evenings/weekends/holidays possible)
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 Fast-paced environment requiring high accuracy and strong prioritization
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 Settings may include community pharmacy, hospital inpatient, ambulatory clinics, specialty pharmacies, or remote/mail order operations
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 </ul>
 
 
 
 
 
 Compensation &amp; Benefits
 
 
 <ul>
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 Competitive compensation
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 Medical, dental, vision, and retirement plans
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 </ul>
 
 
 
 
 
 About Flexzo AI
 
 
 
 Flexzo AI is a specialist healthcare talent partner dedicated to connecting exceptional clinicians with forward-thinking and independent healthcare services across the US. We combine deep sector expertise with advanced AI-driven matching technology to ensure a seamless, personalised recruitment experience for both candidates and employers.
 
 
 
 
 
 By applying through Flexzo AI, you will benefit from:
 
 <ul>
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 A dedicated consultant
 
 guiding you through every stage of the process
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 AI-assisted role matching
 
 to ensure the post aligns with your skills, career goals, and preferred working style
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 Streamlined onboarding support
 
 , including assistance with compliance, documentation, and relocation (if applicable)
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 Exclusive access to roles
 
 across multiple healthcare settings and specialist mental health services
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 </ul>
 
 
 
 
 Flexzo AI is committed to supporting your long-term career development and ensuring you find a post where you can thrive clinically, professionally, and personally.
 
 
 
</div>

Pharmacist

DataAnnotation

<div>
 We are looking for a
 
 Clinical Pharmacist
 
 to join our team to train AI models. You will measure the progress of these AI chatbots, evaluate their logic, and solve problems to improve the quality of each model.
 
 
 In this role, you will need to be an expert in healthcare. We are interested in a wide range of expertise, so relevant backgrounds include Clinical Documentation &amp; HIM, Medication Management (PharmD), Laboratory Medicine and Pathology Services (MLS, MD), Quality Improvement &amp; Patient Safety, Regulatory Compliance, Accreditation &amp; Medical Staff, Care Coordination &amp; Case Management, Population Health &amp; Value-Based Care, and Managed Care &amp; Utilization Management.
 
 
 
 Benefits
 
 
 
 <ul>
 <li>
 Full-time or part-time remote position
 </li>
 <li>
 Choose which projects you want to work on
 </li>
 <li>
 Flexible schedule
 </li>
 <li>
 Projects are paid hourly starting at $50+ per hour
 </li>
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 Bonuses available for high-quality and high-volume work
 
 
 </li>
 </ul>
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Provide AI chatbots with diverse and complex healthcare-related problems
 </li>
 <li>
 Evaluate AI outputs for logic, accuracy, and performance
 </li>
 <li>
 Ensure the medical accuracy and overall quality of model responses
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 <ul>
 <li>
 Fluency in English (native or bilingual level)
 </li>
 <li>
 A current or in-progress medical or healthcare-related degree
 
 
 </li>
 </ul>
 
 Notes:
 
 Payment is made via PayPal. We will never ask you for any money. PayPal will handle any currency conversions from USD. Only applicants in the United States will be considered for this role. This is an independent contractor position.
 
 
 
 #medicine
 
</div>

Clinical Pharmacist

<div>
 We are looking for a
 
 Pharmacy Technician
 
 to join our team to train AI models. You will measure the progress of these AI chatbots, evaluate their logic, and solve problems to improve the quality of each model.
 
 
 In this role, you will need to be an expert in healthcare. We are interested in a wide range of expertise, so relevant backgrounds include Revenue Cycle Management &amp; Patient Finance, Pharmacy Operations (Pharm Tech), Laboratory Services and Operations (Lab Tech), and Clinical Support &amp; Ambulatory Operations.
 
 
 
 Benefits
 
 
 
 <ul>
 <li>
 Full-time or part-time remote position
 </li>
 <li>
 Choose which projects you want to work on
 </li>
 <li>
 Flexible schedule
 </li>
 <li>
 Projects are paid hourly starting at $20+ per hour
 </li>
 <li>
 Bonuses available for high-quality and high-volume work
 
 
 </li>
 </ul>
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Provide AI chatbots with diverse and complex healthcare-related problems
 </li>
 <li>
 Evaluate AI outputs for logic, accuracy, and performance
 </li>
 <li>
 Ensure the medical accuracy and overall quality of model responses
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 <ul>
 <li>
 Fluency in English (native or bilingual level)
 </li>
 <li>
 A current or in-progress medical or healthcare-related degree
 
 
 </li>
 </ul>
 
 Notes:
 
 Payment is made via PayPal. We will never ask you for any money. PayPal will handle any currency conversions from USD. Only applicants in the United States will be considered for this role. This is an independent contractor position.
 
 
 
 #generalist
 
</div>

Pharmacy Technician

<div>
 We are looking for a Nurse to join our team to train AI models. You will measure the progress of these AI chatbots, evaluate their logic, and solve problems to improve the quality of each model.
 
 
 
 Physicians &amp; Advanced Practice Clinicians
 
 
 
 In this role you will need to be an expert in healthcare. We are interested in a wide range of expertise, so relevant backgrounds include:
 
 
 Physicians of all specialties (e.g., Internists, Cardiologists, Oncologists), Physician Assistants, Nurse Practitioners, Certified Nurse-Midwives, Certified Registered Nurse Anesthetists, Clinical Nurse Specialists, Registered Nurses.
 
 
 
 Therapists
 
 
 
 Physical Therapists, Occupational Therapists, Speech-Language Pathologists, Respiratory Therapists, Athletic Trainers, Massage/Recreational Therapists.
 
 
 
 Diagnostic &amp; Laboratory Professionals
 
 
 
 Radiologic Technologists, Sonographers, MRI &amp; Nuclear Medicine Technologists, Medical Laboratory Scientists, Phlebotomists, Histology &amp; Genetics Technicians.
 
 
 
 Public Health &amp; Specialized Roles
 
 
 
 Dietitians/Nutritionists, Genetic Counselors, Epidemiologists, Public Health Nurses.
 
 
 
 Benefits
 
 
 
 <ul>
 <li>
 This is a full-time or part-time REMOTE position
 </li>
 <li>
 You&rsquo;ll be able to choose which projects you want to work on
 </li>
 <li>
 You can work on your own schedule
 </li>
 <li>
 Projects are paid hourly starting at $50-$60 USD per hour, with bonuses on high-quality and high-volume work
 
 
 </li>
 </ul>
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Give AI chatbots diverse and complex healthcare related problems and evaluate their outputs
 </li>
 <li>
 Evaluate the quality produced by AI models for correctness and performance
 </li>
 <li>
 Ensure the medical accuracy of model performance
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 <ul>
 <li>
 Fluency in English (native or bilingual level)
 </li>
 <li>
 A current or in progress medical degree
 
 
 </li>
 </ul>
 Notes: Payment is made via PayPal. We will never ask for any money from you. PayPal will handle any currency conversions from USD. Only applicants in the United States will be considered for this role. This is an independent contract position.
 
 
 #medicine
</div>

Nurse

<div>
 We are looking for medical experts to join our team to train AI models. You will measure the progress of these AI chatbots, evaluate their logic, and solve problems to improve the quality of each model.
 
 
 
 Role
 
 
 
 In this role you will need to be an expert in healthcare. We are interested in a wide range of expertise, so relevant backgrounds include:
 
 
 Physicians &amp; Advanced Practice Clinicians: Physicians of all specialties (e.g., Internists, Cardiologists, Oncologists), Physician Assistants, Nurse Practitioners, Certified Nurse-Midwives, Certified Registered Nurse Anesthetists, Clinical Nurse Specialists, Registered Nurses.
 
 
 Therapists: Physical Therapists, Occupational Therapists, Speech-Language Pathologists, Respiratory Therapists, Athletic Trainers, Massage/Recreational Therapists.
 
 
 Diagnostic &amp; Laboratory Professionals: Radiologic Technologists, Sonographers, MRI &amp; Nuclear Medicine Technologists, Medical Laboratory Scientists, Phlebotomists, Histology &amp; Genetics Technicians.
 
 
 Public Health &amp; Specialized Roles: Dietitians/Nutritionists, Genetic Counselors, Epidemiologists, Public Health Nurses.
 
 
 
 Benefits
 
 
 
 This is a full-time or part-time REMOTE position
 
 
 You&rsquo;ll be able to choose which projects you want to work on
 
 
 You can work on your own schedule
 
 
 Projects are paid hourly starting at $40+ per hour, with bonuses on high-quality and high-volume work
 
 
 
 Responsibilities
 
 
 
 Give AI chatbots diverse and complex healthcare related problems and evaluate their outputs
 
 
 Evaluate the quality produced by AI models for correctness and performance
 
 
 Ensure the medical accuracy of model performance
 
 
 
 Qualifications
 
 
 
 Fluency in English (native or bilingual level)
 
 
 A current or in progress medical degree
 
 
 
 Notes
 
 
 
 Payment is made via PayPal
 
 
 We will never ask for any money from you
 
 
 PayPal will handle any currency conversions from USD
 
 
 Only applicants in the United States will be considered for this role
 
 
 This is an independent contract position.
 
 
 #MEDICINE
</div>

Clinical Nurse