Clinical Appeals Nurse (RN) Remote

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

Job summary

An established industry player is seeking a dedicated Clinical Appeals Specialist to ensure compliance and accuracy in medical claims processing. This remote position offers a chance to utilize your clinical expertise to review appeals, identify quality issues, and support the team with documentation and policy updates. With a focus on mentorship, you'll play a key role in guiding staff while working within a supportive and dynamic environment. Enjoy competitive benefits and the opportunity to make a significant impact in the healthcare sector.

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 and appeals.
• Identify and report quality of care issues in claims processing.
• Provide training and mentorship to staff.

Skills

Clinical Reviews

Medical Claims Processing

ICD-9 Coding

CPT Coding

Regulatory Guidelines

Quality of Care Reporting

Training and Mentorship

Education

Bachelor's Degree in Nursing

Graduate from an accredited nursing school

Tools

MCG

InterQual

CMS Guidelines

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. Responsibilities include performing clinical/medical reviews of retrospective medical claim reviews, medical claims, and previously denied cases with submitted appeals to ensure medical necessity and accurate billing and claims processing. The role involves identifying and reporting quality of care issues, assisting with complex claim reviews, and documenting findings in the database. It also includes providing supporting documentation for denial and modification of payment decisions.

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/medical reviews of denied cases with formal appeals or upon departmental request to reduce formal appeal submissions.
• Re-evaluate medical claims independently using advanced clinical knowledge, regulatory guidelines, Molina policies, and individual judgment.
• Apply appropriate criteria on PAR and Non-PAR cases and 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 hearings and appeals, representing Molina effectively.
• Serve as a clinical resource and provide training and mentorship to staff.
• Support team with documentation, policy updates, and application testing.
• Understand operational processes related to PI MCR and 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, including specialties like surgical, Ob/Gyn, home health, pharmacy, etc.
• Knowledge of ICD-9, CPT, HCPCS coding, 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 experience, 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

Interested Molina employees should apply through the intranet. Molina offers competitive benefits and is an Equal Opportunity Employer. Pay range: $77,969 - $141,371 annually, with actual compensation varying based on location, experience, education, and skills.