Clinical Appeals Nurse (RN) Remote

Lensa; Atlanta (GA); Remote; USD 77,000 - 142,000; Full time

Job summary

An innovative healthcare organization is seeking a dedicated Clinical Appeals Specialist to join their remote team. This role is essential in ensuring compliance and accuracy in clinical decision-making for appeals outcomes. The ideal candidate will leverage their clinical nursing expertise to conduct thorough reviews of medical claims and denied cases, ensuring medical necessity and appropriate billing. You'll have the opportunity to mentor others while working in a supportive environment that values your contributions. If you're passionate about improving healthcare processes and making a difference in patients' lives, this position is perfect for you.

Qualifications

• 3-5 years of clinical nursing experience required.
• Active, unrestricted State RN license is mandatory.

Responsibilities

• Perform clinical reviews of denied cases to reduce appeal submissions.
• Identify and report quality of care issues effectively.

Skills

Clinical Reviews

ICD-9 Coding

CPT Coding

HCPCS Coding

Regulatory Knowledge

Quality of Care Reporting

Documentation Skills

Training and Mentorship

Education

Bachelor's Degree in Nursing

Graduate from an accredited School of Nursing

Job description

Be among the first 25 applicants.

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 where an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing. It also involves identifying and reporting quality of care issues, assisting with complex claim reviews, and documenting findings.

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

Knowledge/Skills/Abilities

• Perform clinical/medical reviews of denied cases to reduce formal appeal submissions.
• Re-evaluate medical claims applying advanced clinical knowledge, regulatory requirements, and organizational policies.
• Apply appropriate criteria on various cases and review clinical guidelines with the Chief Medical Officer.
• Resolve escalated complaints regarding Utilization Management and Long-Term Services & Supports.
• Identify and report quality of care issues.
• Prepare and present cases for hearings and regulatory bodies.
• Represent Molina effectively in hearings.
• Serve as a clinical resource and provide training and mentorship.
• Support team with documentation, process improvements, and testing new applications.
• Understand 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 clinical nursing experience, with 1-3 years in Managed Care or equivalent.
• Knowledge of ICD-9, CPT, HCPCS coding, and CMS guidelines.

Required License/Certification

Active, unrestricted State RN license.

Preferred Education

Bachelor's Degree in Nursing.

Preferred Experience

5+ years clinical nursing experience, including hospital acute care.

Preferred Certifications

• Certified Clinical Coder
• Certified Medical Audit Specialist
• Certified Case Manager
• Other healthcare certifications

To apply, current Molina employees should use the intranet. Molina offers competitive benefits. Equal Opportunity Employer. Pay range: $77,969 - $141,371 annually.