Registered Nurse

JOB DESCRIPTION

Job Summary

The Clinical Appeals Nurse (RN) provides support for internal appeals clinical processes - ensuring that appeals requests are reevaluated in alignment with applicable federal and state regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Assesses appropriateness of services, length of stay and level of care provided to members. Contributes to overarching strategy to provide quality and cost-effective member care. Candidates with UM and Appeals experience are highly preferred

Work hours : Monday- Friday 8 : 00am - 5 : 00pm Central time

Remote position

Essential Job Duties

• 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.
• Reevaluates medical claims and associated records independently by applying advanced clinical knowledge, knowledge of all 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 decisions.
• Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) 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 experienced appeals nurses and administrative team members.

Required Qualifications

Preferred Qualifications

To all current Molina employees : If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M / F / D / V

Pay Range : $77,969 - $141,371 / ANNUAL