Clinical Appeals Nurse (RN) Remote

Lensa; Caldwell (ID); Remote; USD 77,000 - 142,000; Full time

Job summary

An established industry player in healthcare is seeking a Clinical Appeals Specialist to join their remote team. This role is vital in making clinical decisions for appeals outcomes while ensuring compliance and quality of care. The ideal candidate will possess an unrestricted RN license and have significant clinical nursing experience. You will be responsible for reviewing medical claims, documenting findings, and supporting the team with process improvements. Join a dynamic organization that values your expertise and offers competitive benefits, making a real impact in the healthcare field.

Qualifications

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

Responsibilities

• Perform clinical reviews of denied cases to reduce formal appeals.
• Prepare and present cases for legal and insurance hearings.

Skills

Clinical Review

ICD-9 Coding

CPT Coding

HCPCS Coding

Regulatory Knowledge

Mentorship

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 clinical/medical reviews of retrospective medical claim reviews, medical claims, and previously denied cases, to ensure medical necessity and accurate billing. It also involves identifying and reporting quality of care issues, assisting with complex claim reviews, and documenting findings in the database.

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 reviews of denied cases to reduce formal appeals.
• Re-evaluate medical claims applying advanced clinical knowledge and regulatory requirements.
• 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 insurance hearings, representing Molina effectively.
• 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 general healthcare administration.

Job Qualifications

Required Education

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

Required Experience

• 3-5 years of clinical nursing experience, with 1-3 years in Managed Care or equivalent.
• Knowledge of ICD-9, CPT, HCPCS coding, and clinical guidelines like CMS, MCG, InterQual.

Required License

Active, unrestricted State RN license in good standing.

Preferred Education

Bachelor's Degree in Nursing.

Preferred Experience

• 5+ years of clinical nursing, including hospital acute care.

Preferred Certifications

• Certified Clinical Coder, Medical Audit Specialist, Case Manager, Healthcare Management, Healthcare Quality, or similar.

Interested Molina employees should apply through the intranet. Molina offers competitive benefits. This is an EOE M/F/D/V. Pay range: $77,969 - $141,371 annually, varies by location and experience.