JOB SEEKERS

JOB LISTINGS

  • Share this Job

Clinical Appeals Nurse (RN)

Location : Irving, TX
Job Type : Contract
Reference Code : 14679
Hours : Full Time
Required Years of Experience : 3-5
Required Education : Graduate from an Accredited School of Nursing
Travel : No
Relocation : No
Job Industry : Healthcare - Health Services
Job Category : Healthcare - RNs & Nurse Management

Job Description :
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 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 & 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 experienced appeal LVN, RN and administrative staff.

JOB FUNCTION:
Clinical Appeals is responsible for making appropriate and correct clinical decisions for appeals outcomes within compliance standards.
Required Qualifications :
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.



REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:
Active, unrestricted State Registered Nursing (RN) license in good standing.



REQUIRED EDUCATION:
Graduate from an Accredited School of Nursing.



PREFERRED EXPERIENCE:
5+ years Clinical Nursing experience, including hospital acute care/medical experience.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:
Any one or more of the following:
Certified Clinical Coder, Certified Medical Audit Specialist, Certified Case Manager , Certified Professional Healthcare Management, Certified Professional in Healthcare Quality or other healthcare certification.



PREFERRED EDUCATION:
Bachelor’s Degree in Nursing
Powered by AkkenCloud