Clinical Appeals Nurse (RN)

Molina Healthcare • Albany, NY

241d • $77,969 - $141,371

About The Position

The Clinical Appeals Nurse (RN) is responsible for making appropriate and correct clinical decisions for appeals outcomes within compliance standards. This role involves performing 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. The nurse 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. The nurse applies appropriate criteria on PAR and Non-PAR cases and with Marketplace EOCs. They also review medically appropriate clinical guidelines and other appropriate criteria with the Chief Medical Officer on denial decisions, resolve escalated complaints regarding Utilization Management and Long-Term Services & Supports issues, identify and report quality of care issues, and prepare and present cases in conjunction with the Chief Medical Officer for various hearings. Additionally, the nurse serves as a clinical resource for Utilization Management, Chief Medical Officer, Physicians, and Member/Provider Inquiries/Appeals, and provides training, leadership, and mentoring for less experienced appeal staff.

Requirements

• Graduate from an Accredited School of Nursing.
• 3-5 years clinical nursing experience.
• 1-3 years Managed Care Experience in relevant programs.
• Knowledge of ICD-9, CPT coding, and HCPC.
• Knowledge of CMS Guidelines, MCG, InterQual, Medicaid, Medicare, CHIP, and Marketplace.

Nice To Haves

• Bachelor's Degree in Nursing.
• 5+ years Clinical Nursing experience, including hospital acute care.
• Active and unrestricted Certified Clinical Coder.
• Certified Medical Audit Specialist.
• Certified Case Manager.
• Certified Professional Healthcare Management.
• Certified Professional in Healthcare Quality.

Responsibilities

• Perform clinical/medical reviews of previously denied cases.
• Independently re-evaluate medical claims and associated records.
• Apply advanced clinical knowledge and relevant regulatory requirements.
• Assess appropriateness of service provided, length of stay, and level of care.
• Apply appropriate criteria on PAR and Non-PAR cases.
• Review clinical guidelines with Chief Medical Officer on denial decisions.
• Resolve escalated complaints regarding Utilization Management.
• Identify and report quality of care issues.
• Prepare and present cases for Administrative Law Judge pre-hearings.
• Represent Molina during Fair Hearings as required.
• Serve as a clinical resource for various stakeholders.
• Provide training and mentoring for less experienced staff.

Benefits

• Competitive benefits and compensation package.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Insurance Carriers and Related Activities
• Education Level: Bachelor's degree