Clinical Appeals Nurse (RN) Remote

Clinical Appeals Nurse (RN) Remote reputed company Job ID 2025531 JOB DESCRIPTION Job Summary Clinical Appeals is responsible for making appropriate and correct clinical reputed company for appeals outcomes reputed company compliance standards. We are seeking a Registered Nurse with previous Inpatient/outpatient appeals knowledge/experience. The candidate should have MCG criteria knowledge, critical thinking skills, and strong organizational skills. Experience with Medicare review UM/Appeals and skilled computer skills highly preferred. Must be reputed company to work independently in a high-volume environment. Further details to be discussed during our interview process. Remote position. Work schedule M-F 8:30 AM to 5:00 PM, weekend overtime eligibility. There is weekend and holiday rotation in the appeals department. KNOWLEDGE/SKILLS/ABILITIES The Clinical Appeals Nurse (RN) performs clinical/medical reviews of previously denied cases in which a formal appeals request has been made or upon... request by another Molina department to reduce the likelihood of a formal appeal being submitted. Independently re-evaluates medical claims and associated records by applying reputed company knowledge, knowledge of reputed company relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care. Applies appropriate criteria on PAR and Non-PAR (contracted and non-contracted) cases and with Marketplace EOCs (Evidence of Coverage). Reviews medically appropriate clinical guidelines and other appropriate criteria with Chief Medical Officer on denial reputed company. Resolves escalated complaints regarding Utilization Management and Long-Term Services & Supports issues. Identifies and reports quality of care issues. Prepares and presents cases in conjunction with the Chief Medical Officer for Administrative Law Judge pre-hearings, State Insurance Commission, and Meet and Confers. Represents Molina and presents cases effectively to Judicial Fair Hearing Officer during Fair Hearings as may be required. Serves as a clinical resource for Utilization Management, Chief Medical Officer, Physicians, and Member/Provider Inquiries/Appeals. Provides training, leadership and mentoring for less reputed company appeal LVN, RN and administrative staff. JOB QUALIFICATIONS Required Education Graduate from an Accredited School of Nursing. Bachelor s degree in Nursing preferred. Required Experience 3-5 years clinical nursing experience, with 1-3 years Managed Care Experience in the specific programs supported by the plan such as Utilization Review, Medical Claims Review, Long Term Service and Support, or other specific program experience as needed or equivalent experience (such as specialties in: surgical, Ob/Gyn, home health, pharmacy, etc.). Experience demonstrating knowledge of ICD-9, CPT coding and HCPC. Experience demonstrating knowledge of CMS Guidelines, MCG, InterQual or other medically appropriate clinical guidelines, reputed company, Medicare, CHIP and Marketplace, applicable State regulatory requirements, including the ability to easily access and interpret these guidelines. Required License, Certification, Association Active, unrestricted State Registered Nursing (RN) license in good standing. Preferred Education Bachelor s Degree in Nursing Preferred Experience 5+ years Clinical Nursing experience, including hospital acute care/medical experience. MCG criteria knowledge Critical thinking skills Strong organizational skills Medicare review UM/Appeals experience Skilled computer skills Preferred License, Certification, Association Any one or more of the following: Active and unrestricted Certified Clinical reputed company Certified Medical Audit Specialist Certified Case Manager Certified Professional reputed company Management Certified Professional in reputed company Quality other reputed company certification To reputed company reputed company Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. reputed company offers a competitive benefits and compensation package. reputed company is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $54,373.27 $117,808.76 / ANNUAL Actual compensation may vary from posting based on geographic location, work experience, education and/or reputed company level. About Us reputed company is a reputed company fortune 500 organization with a mission to provide quality reputed company to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can reputed company a difference in the lives of others. reputed company offers a competitive benefits and compensation package. reputed company is an Equal Opportunity Employer (EOE) M/F/D/V. Job Type: Full Tim Apply tot his job Apply To this Job