Clinical Appeals Nurse (RN) Remote

Lensa; Akron (OH); Remote; USD 77,000 - 142,000; Full time

Job summary

An established industry player in healthcare is seeking a skilled Clinical Appeals professional to ensure compliance and quality in claims processing. This remote role involves conducting clinical reviews, resolving escalated complaints, and mentoring junior staff. The ideal candidate will possess an unrestricted RN license and have a strong background in clinical nursing with knowledge of coding and regulations. Join a dynamic team that values expertise and offers competitive benefits, all while making a significant impact in the healthcare sector.

Qualifications

• 3-5 years of clinical nursing experience required.
• Active, unrestricted State RN license in good standing.

Responsibilities

• Perform clinical reviews of denied cases and re-evaluate medical claims.
• Prepare and present cases for legal and regulatory hearings.

Skills

Clinical Reviews

ICD-9 Coding

CPT Coding

HCPC Coding

Regulatory Compliance

Mentorship

Process Improvement

Education

Bachelor's Degree in Nursing

Graduate from an accredited School of Nursing

Job description

Lensa is the leading career site for job seekers at every stage of their career. Our client, Molina Healthcare, is seeking professionals. Apply via Lensa today!

Job Description

Job Summary

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

This position supports our Claims business. The candidate must have an unrestricted RN license. The role involves performing clinical/medical reviews of retrospective medical claim reviews, medical claims, and previously denied cases, to ensure medical necessity and accurate billing and claims processing. It also involves identifying and reporting quality of care issues and assisting with complex claim reviews.

This is a remote position with work hours from Monday to Friday, 8:00 am to 5:00 pm, with occasional weekends as needed. Unrestricted RN licensure is required.

Knowledge/Skills/Abilities

• Perform clinical/medical reviews of denied cases upon formal appeal or request.
• Re-evaluate medical claims applying advanced clinical knowledge and relevant regulations.
• Apply appropriate criteria on various case types and review clinical guidelines with leadership.
• Resolve escalated complaints and report quality of care issues.
• Prepare and present cases for legal and regulatory hearings.
• Represent Molina effectively during hearings and serve as a clinical resource.
• Provide training and mentorship to less experienced staff.
• Support team with documentation, process improvements, and application testing.
• Maintain understanding of operational processes related to PI MCR and healthcare administration.

Job Qualifications

Required Education

Graduate from an accredited School of Nursing; Bachelor's degree preferred.

Required Experience

• 3-5 years of clinical nursing experience, with 1-3 years in Managed Care or related fields.
• Knowledge of ICD-9, CPT, HCPC coding, and CMS guidelines.

Required License

Active, unrestricted State RN license in good standing.

Preferred Education

Bachelor's Degree in Nursing.

Preferred Experience

Over 5 years of clinical nursing experience, including hospital acute care.

Preferred Certifications

• Certified Clinical Coder
• Certified Medical Audit Specialist
• Certified Case Manager
• Certified Professional Healthcare Management
• Certified in Healthcare Quality

Interested Molina employees should apply through the intranet. Molina offers competitive benefits. Equal Opportunity Employer. Pay range: $77,969 - $141,371 annually, varies by location and experience.