Clinical Appeals Nurse (RN) Remote

Lensa; Warren (MI); Remote; USD 65,000 - 95,000; Full time

Job summary

An established industry player is seeking a Clinical Appeals Nurse to join their remote team. This role involves making critical clinical decisions on appeals outcomes, ensuring compliance with regulations, and conducting thorough reviews of medical claims. The ideal candidate will have a strong background in nursing with expertise in managed care, coding, and healthcare administration. You will play a vital role in improving patient care and operational processes while providing mentorship to junior staff. If you are passionate about making a difference in healthcare, this opportunity is perfect for you.

Qualifications

• 3-5 years of clinical nursing experience, with 1-3 years in Managed Care.
• Active, unrestricted RN license in good standing is required.

Responsibilities

• Perform clinical reviews of medical claims and appeals.
• Identify and report quality of care issues.
• Document clinical review summaries and audit findings.

Skills

Clinical Decision-Making

ICD-9 Coding

CPT Coding

HCPC Coding

Managed Care Knowledge

Quality of Care Reporting

Healthcare Administration Knowledge

Education

Bachelor's Degree in Nursing

Graduate from an accredited school of nursing

Tools

InterQual

MCG

CMS Guidelines

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 will support our Claims business. The candidate must have an unrestricted RN license. This position performs clinical/medical reviews of retrospective medical claim reviews, medical claims, and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing. Identifies and reports quality of care issues. Assists with complex claim review 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. Documents clinical review summaries, bill audit findings, and audit details in the database. Provides supporting documentation for denial and modification of payment decisions.

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

Knowledge/Skills/Abilities

• The Clinical Appeals Nurse (RN) performs reviews of previously denied cases upon formal appeal or request from other Molina departments to reduce the likelihood of a formal appeal being submitted.
• Re-evaluates medical claims and records applying advanced clinical knowledge, relevant federal and state regulations, Molina policies, and individual judgment to assess service appropriateness, length of stay, and level of care.
• Applies appropriate criteria on PAR and Non-PAR cases, including Marketplace EOCs.
• Reviews clinical guidelines with the Chief Medical Officer on denial decisions.
• Resolves escalated complaints regarding Utilization Management and Long-Term Services & Supports issues.
• Identifies and reports quality of care issues.
• Prepares and presents cases for hearings and regulatory reviews.
• Represents Molina effectively during fair hearings.
• Serves as a clinical resource for various teams and inquiries.
• Provides training, leadership, and mentorship to less experienced staff.
• Re-evaluates claims applying advanced knowledge and regulatory guidelines.
• Supports policy updates, process improvements, and application testing.
• Understands operational processes related to PI MCR.
• Possesses 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 or equivalent.
• Knowledge of ICD-9, CPT, HCPC coding.
• Understanding of CMS Guidelines, MCG, InterQual, Medicaid, Medicare, CHIP, Marketplace, and applicable state regulations.

Required License, Certification, Association

Active, unrestricted RN license in good standing.

Preferred Education

Bachelor's Degree in Nursing.

Preferred Experience

Over 5 years of clinical nursing, including hospital acute care or medical experience.

Preferred Certifications

• Certified Clinical Coder
• Certified Medical Audit Specialist
• Certified Case Manager
• Certified Healthcare Management Professional
• Certified in Healthcare Quality