Clinical Appeals Nurse (RN)

Molina Healthcare; Bridgeport (CT); Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare provider is seeking a Registered Nurse (RN) for a remote role focusing on clinical appeals within compliance standards. The ideal candidate will have 3-5 years of clinical nursing experience and must be knowledgeable in ICD-9, CPT coding, and CMS guidelines. Strong analytical and multi-tasking skills are essential. This position offers a competitive benefits package and requires a state RN license.

Benefits

Competitive benefits and compensation package

Work-from-home flexibility

Qualifications

• Graduate from an Accredited School of Nursing.
• Active, unrestricted RN license in good standing.
• 3-5 years clinical nursing experience required.

Responsibilities

• Perform medical reviews of appealed cases.
• Independently re-evaluate medical claims.
• Provide training and mentoring to less experienced staff.

Skills

Clinical nursing experience

Knowledge of ICD-9, CPT coding

Analytical thought process

Computer multi-tasking

Experience with CMS guidelines

Education

Registered Nursing license

Bachelor's Degree in Nursing

Tools

Clinical guidelines knowledge

Job description

Registered Nurse (RN)

Job Description

For this position we are seeking a Registered Nurse (RN) who must be licensed for the state they reside. This position will support Medical Review for Medicare and Marketplace request authorization. Strongly prefer candidates with a background in appeals and grievances.

Excellent computer multi-tasking skills and good productivity is essential for this fast-paced role. Good analytical thought process is important to be successful in this role.

This is a productivity environment.

Work Schedule : Friday to Tuesday 8 : 00AM to 5 : 00PM EST (Occasional holidays required) (Working Friday, Saturday, Sunday, Monday, and Tuesday)

This is a remote position, home office with internet connectivity of high speed required.

Job Summary

Clinical Appeals is responsible for making appropriate and correct clinical decisions for appeals outcomes within compliance standards.

Knowledge / Skills / Abilities

• The Clinical Appeals Nurse (RN) performs clinical / medical reviews of previously denied cases in which a formal appeals request has been made or upon request by another Molina department to reduce the likelihood of a formal appeal being submitted.
• Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care.
• Applies appropriate criteria on PAR and Non-PAR (contracted and non-contracted) cases and with Marketplace EOCs (Evidence of Coverage).
• Reviews medically appropriate clinical guidelines and other appropriate criteria with Chief Medical Officer on denial decisions.
• Resolves escalated complaints regarding Utilization Management and Long-Term Services & Supports issues.
• Identifies and reports quality of care issues.
• Prepares and presents cases in conjunction with the Chief Medical Officer for Administrative Law Judge pre-hearings, State Insurance Commission, and Meet and Confers.
• Represents Molina and presents cases effectively to Judicial Fair Hearing Officer during Fair Hearings as may be required.
• Serves as a clinical resource for Utilization Management, Chief Medical Officer, Physicians, and Member / Provider Inquiries / Appeals.
• Provides training, leadership and mentoring for less experienced appeal LVN, RN and administrative staff.

Job Qualifications

Required Education

Graduate from an Accredited School of Nursing. Bachelor's degree in Nursing preferred.

Required Experience

3-5 years clinical nursing experience, with 1-3 years Managed Care Experience in the specific programs supported by the plan such as Utilization Review, Medical Claims Review, Long Term Service and Support, or other specific program experience as needed or equivalent experience (such as specialties in : surgical, Ob / Gyn, home health, pharmacy, etc.).

Experience demonstrating knowledge of ICD-9, CPT coding and HCPC.

Experience demonstrating knowledge of CMS Guidelines, MCG, InterQual or other medically appropriate clinical guidelines, Medicaid, Medicare, CHIP and Marketplace, applicable State regulatory requirements, including the ability to easily access and interpret these guidelines.

Required License, Certification, Association

Active, unrestricted State Registered Nursing (RN) license in good standing.

Preferred Education

Bachelor's Degree in Nursing

Preferred Experience

5+ years Clinical Nursing experience, including hospital acute care / medical experience.

Preferred License, Certification, Association

Active and unrestricted Certified Clinical Coder

Certified Medical Audit Specialist

Certified Case Manager

Certified Professional Healthcare Management

Certified Professional in Healthcare Quality

Other healthcare certification

To all current Molina employees : If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M / F / D / V.