Clinical Appeals Nurse (RN) Remote

Lensa; Miami (FL); Remote; USD 77,000 - 142,000; Full time

Job summary

An established industry player is seeking a skilled Clinical Appeals professional to ensure compliance and accuracy in medical claims. This remote position requires an unrestricted RN license and offers the opportunity to make impactful clinical decisions. You'll perform medical reviews, identify quality issues, and provide mentorship to junior staff. Join a forward-thinking team that values expertise and offers competitive benefits. If you have a passion for healthcare and a commitment to excellence, this role is a perfect fit for you.

Qualifications

• Active, unrestricted State RN license required.
• 3-5 years clinical nursing experience in Managed Care preferred.

Responsibilities

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

Skills

Clinical Reviews

ICD-9 Coding

CPT Coding

HCPC Coding

Regulatory Knowledge

Quality of Care Reporting

Leadership

Healthcare Administration

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.

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

Knowledge/Skills/Abilities

• Perform clinical/medical reviews of denied cases to reduce formal appeals.
• Re-evaluate medical claims applying advanced clinical knowledge and regulatory requirements.
• 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 legal and insurance hearings.
• Represent Molina effectively in hearings and serve as a clinical resource.
• Provide training, leadership, and mentoring to less experienced staff.
• Support team with policy updates, documentation, and application testing.
• Understand operational processes related to PI MCR and general healthcare administration knowledge.

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, HCPC coding, CMS Guidelines, and applicable regulations.

Required License, Certification, Association

Active, unrestricted State RN license.

Preferred Education

Bachelor's Degree in Nursing.

Preferred Experience

5+ years clinical nursing, including hospital acute care. Additional healthcare certifications are a plus.

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