Clinical Appeals Nurse (RN) Remote

Lensa; New York (NY); Remote; USD 77,000 - 142,000; Full time

Job summary

An established industry player in healthcare is seeking a Clinical Appeals Nurse to provide critical clinical reviews for appeals outcomes. This remote role requires an unrestricted RN license and offers the opportunity to leverage your clinical expertise in a dynamic environment. You will be responsible for evaluating medical claims, identifying quality of care issues, and supporting the Claims business with your advanced clinical knowledge. Join a team that values your contributions and offers competitive benefits while making a significant impact on patient care and operational excellence.

Qualifications

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

Responsibilities

• Review previously denied cases and assess appropriateness of services.
• Document clinical review summaries and audit findings.

Skills

Clinical Decision Making

ICD-9 Coding

CPT Coding

HCPCS Knowledge

Utilization Review

Healthcare Administration

Education

Bachelor's Degree in Nursing

Graduate from an Accredited School of Nursing

Job description

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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 and claims processing. It also includes identifying and reporting quality of care issues, assisting with complex claim reviews (such as DRG validation, bill review, appropriate level of care, inpatient readmission), and documenting review summaries and audit findings. The position provides supporting documentation for denial and payment modifications.

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

• Review previously denied cases upon appeal or request to reduce formal appeal submissions.
• Re-evaluate medical claims using clinical knowledge, regulations, policies, and judgment to assess service appropriateness, length of stay, and care level.
• Apply appropriate criteria on PAR and Non-PAR cases and with Marketplace EOCs.
• Review clinical guidelines with the Chief Medical Officer for denial decisions.
• Resolve escalated complaints related to Utilization Management and Long-Term Services & Supports.
• Identify and report quality of care issues.
• Prepare and present cases for legal and regulatory hearings, representing Molina effectively.
• Serve as a clinical resource, providing training and mentorship to staff.
• Support team documentation, process improvements, and testing of new applications.
• Understand operational processes related to PI MCR to resolve issues.
• Possess general healthcare administration knowledge.

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 (e.g., Utilization Review, Medical Claims Review, Long Term Services & Supports, or related fields).
• Knowledge of ICD-9, CPT coding, and HCPCS.
• Understanding of CMS Guidelines, MCG, InterQual, Medicaid, Medicare, CHIP, Marketplace, and relevant state 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, including hospital acute care/medical experience.

Preferred Certifications

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

Interested Molina employees should apply through the intranet. Molina offers competitive benefits. Equal Opportunity Employer. Pay Range: $77,969 - $141,371 annually. Actual pay varies based on location, experience, education, and skills.

Additional Details

• Seniority level: Mid-Senior level
• Employment type: Full-time
• Job function: Healthcare Provider
• Industries: IT Services and Consulting

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