Clinical Appeals Nurse (RN) Remote

Lensa; Chandler (AZ); Remote; USD 77,000 - 142,000; Full time

Job summary

An established industry player is seeking a dedicated Clinical Appeals Nurse to join their team. This remote role will involve making critical clinical decisions on appeals, ensuring compliance, and supporting the Claims business. The ideal candidate will possess an unrestricted RN license and have extensive experience in clinical nursing, particularly within Managed Care. You will engage in clinical reviews, mentor staff, and contribute to policy improvements. This position offers a vibrant work environment with a focus on quality care and professional growth, making it a perfect opportunity for those passionate about healthcare excellence.

Benefits

Competitive Benefits

Remote Work Flexibility

Professional Development Opportunities

Qualifications

• 3-5 years of clinical nursing experience, with a focus on Managed Care.
• Active, unrestricted State RN license required.

Responsibilities

• Conduct clinical reviews of denied claims and appeals.
• Identify quality of care issues and prepare cases for hearings.

Skills

Clinical Medical Reviews

ICD-9 Coding

CPT Coding

HCPCS

CMS Guidelines

Quality of Care Reporting

Training and Mentoring

Healthcare Administration Knowledge

Education

Bachelor's Degree in Nursing

Graduate from an Accredited School of Nursing

Tools

MCG

InterQual

Healthcare Software Applications

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

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

Knowledge/Skills/Abilities

• Perform clinical/medical reviews of denied cases upon appeal or request to reduce formal appeals.
• Re-evaluate medical claims applying advanced clinical knowledge and relevant regulations and policies.
• Apply appropriate criteria on PAR and Non-PAR cases, including Marketplace EOCs.
• Review clinical guidelines with the Chief Medical Officer on denial decisions.
• Resolve escalated complaints regarding Utilization Management and Long-Term Services & Supports.
• Identify and report quality of care issues.
• Prepare and present cases for legal and regulatory hearings.
• Represent Molina effectively during Fair Hearings.
• Serve as a clinical resource for various departments and inquiries.
• Provide training, leadership, and mentoring to less experienced staff.
• Support policy updates and process improvements.
• Test new applications and software updates.
• Understand operational processes related to PI MCR.
• Possess general healthcare administration knowledge.

Job Qualifications

Required Education

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

Required Experience

• 3-5 years of clinical nursing experience, with 1-3 years in Managed Care or related programs.
• Knowledge of ICD-9, CPT coding, HCPCS, CMS Guidelines, MCG, InterQual, and applicable regulations.

Required License, Certification, Association

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/medical experience.

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 Healthcare offers competitive benefits. We are an Equal Opportunity Employer. Pay range: $77,969 - $141,371 annually, vary based on location and experience.