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Posted: 10/20/2026Manager, Clinical Appeals
CareSourceCore Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in managing clinical appeals processes, ensuring compliance with state regulations and organizational policies. Proficient in data analysis, workflow optimization, and maintaining departmental policies to enhance operational efficiency.
Highest-signal resume keywords
Clinical Appeals ManagementUtilization ManagementData AnalysisRegistered Nurse (RN) LicensureMCG Certification
About the role
Key responsibilities & impact- Coordinate and manage the clinical appeals process related to adverse benefit determinations
- Ensure consistent application of clinical appeals criteria
- Oversee clinical appeals data and processes, including decisions within allowable timeframes
- Interact with providers and staff to manage benefits aligned with state regulations, NCQA and CareSource policies
- Review and revise workflows to maximize efficiencies
- Monitor productivity, turnaround time and volume trends
- Oversee CQI activities, audits and regular staff feedback
- Report clinical appeals regulatory requirements and maintain reporting and trend data
- Analyze utilization, state hearing, non-formulary exception, external and Independent Review Entity outcome data
- Develop, maintain and update departmental policies and procedures
- Ensure notices of adverse action are provided according to regulations
- Audit clinical appeal cases for documentation and interrater reliability
- Liaise with other departments for research and intervention
Requirements
What you’ll need- Associate’s Degree in Nursing is required; Bachelor of Science in Nursing (BSN) preferred
- Minimum of five (5) years of clinical experience required
- Minimum of five (5) years of experience in utilization management, appeals, and/or quality improvement required
- Current, unrestricted licensure in state of practice as a Registered Nurse (RN) required
- MCG Certification required or must be obtained within six (6) months of hire
- Beginning Excel, Word and PowerPoint experience
- Experience in data analysis and trending
- Knowledge of utilization management standards and practices
- Management and prior supervisory skills
- Ability to work independently and within a team environment
- Familiarity with the health care field
- Critical listening and thinking skills
- Training/teaching skills
- Strategic management skills
- Negotiation skills/experience
- Technical writing skills
- Leadership experience and skills
Benefits
Comp & perks- Bonus tied to company and individual performance may be available
- Substantial and comprehensive total rewards package
- Remote work arrangement
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Appeals ProcessUtilization Management StandardsData AnalysisWorkflow OptimizationPolicy DevelopmentAuditing SkillsRegulatory ComplianceDocumentation ReviewTrend AnalysisQuality Improvement
Soft Skills
Critical ThinkingNegotiation SkillsLeadership SkillsTraining SkillsTeam Collaboration
Tools & Technologies
ExcelWordPowerPoint
Certifications & Qualifications
MCG CertificationRegistered Nurse (RN) Licensure
Industry Keywords
Clinical AppealsAdverse Benefit DeterminationsNCQACareSource PoliciesCQI Activities