Clinical Appeals Nurse (RN) Remote

Lensa; Orem (UT); Remote; USD 77,000 - 142,000; Full time

Job summary

An established industry player is seeking a dedicated Clinical Appeals Nurse to join their dynamic team. This remote position offers the opportunity to make impactful clinical decisions and ensure compliance with healthcare standards. You will be responsible for reviewing medical claims, resolving escalated complaints, and serving as a clinical resource across departments. If you have a passion for patient care and a strong background in clinical nursing, this role offers a competitive salary and a chance to contribute to meaningful healthcare outcomes.

Qualifications

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

Responsibilities

• Perform clinical/medical reviews of denied cases.
• Document clinical review summaries and audit findings.
• Provide training and mentorship to less experienced staff.

Skills

Clinical decision-making

ICD-9 coding

CPT coding

HCPCS knowledge

Regulatory understanding

Analytical skills

Education

Bachelor's Degree in Nursing

Graduate from an accredited nursing school

Tools

Healthcare administration software

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. Identifies and reports quality of care issues. Assists with complex claim reviews, including DRG validation, itemized bill review, appropriate level of care, inpatient readmission, and other opportunities identified by the Payment Integrity analytical team. Requires clinical decision-making based on experience. Documents clinical review summaries, bill audit findings, and audit details in the database. Provides supporting documentation for denial and modification of payment decisions.

Remote position with work hours: Monday - Friday, 8:00 am - 5:00 pm, with occasional weekends as needed.

Unrestricted RN licensure is required.

Knowledge/Skills/Abilities

• The Clinical Appeals Nurse (RN) performs reviews of previously denied cases upon formal appeal or departmental request to reduce formal appeals.
• Re-evaluates medical claims independently, applying advanced clinical knowledge, relevant federal and state regulations, Molina policies, and individual judgment.
• Applies appropriate criteria on PAR and Non-PAR cases and with Marketplace EOCs.
• Reviews clinical guidelines with Chief Medical Officer on denial decisions.
• Resolves escalated complaints related to Utilization Management and Long-Term Services & Supports.
• Identifies and reports quality of care issues.
• Prepares and presents cases for legal and insurance hearings.
• Represents Molina effectively during Fair Hearings as required.
• Serves as a clinical resource for various departments and staff.
• Provides training, leadership, and mentorship to less experienced staff.
• Re-evaluates claims with advanced knowledge and regulatory understanding.
• Reviews clinical guidelines with Medical Directors on denial decisions.
• Supports recommendations for denial or payment modifications.
• Serves as a subject matter expert for utilization management and appeals.
• Provides training and support to peers.
• Identifies members with special needs for appropriate programs.
• Resolves escalated medical claim review disputes.
• Performs analytical review and validation tasks.
• Updates policies and procedures.
• Supports team lead with documentation, research, and process improvements.
• Tests new applications and software updates.
• Understands operational processes related to PI MCR.
• Possesses general healthcare administration knowledge.

Job Qualifications

Required Education

Graduate from an accredited nursing school; Bachelor's degree preferred.

Required Experience

• 3-5 years of clinical nursing experience, with 1-3 years in Managed Care or equivalent experience in specialties like surgical, Ob/Gyn, home health, pharmacy, etc.
• Knowledge of ICD-9, CPT coding, and HCPCS.
• Understanding of CMS Guidelines, MCG, InterQual, Medicaid, Medicare, CHIP, Marketplace, and applicable 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

• Active and unrestricted Certified Clinical Coder
• Certified Medical Audit Specialist
• Certified Case Manager
• Certified Professional Healthcare Management
• Certified Professional in Healthcare Quality
• Other healthcare certifications

Current Molina employees should apply through the intranet. Molina offers competitive benefits. We are an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $77,969 - $141,371 annually. Actual compensation varies based on location, experience, education, and skills.