RN Clinical Appeals Nurse Remote

Molina Healthcare•Long Beach, AZ

5d•Remote

About The Position

The RN Clinical Appeals Nurse 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. We are seeking a candidate with a RN licensure, Diagnosis-Related Group (DRG) experience, 2 years of Utilization Review and/or Medical Claims Review experience. Knowledge in coding: DRG, ICD-10, HCPCS codes is highly preferred. Additional experience with 2 years in claims auditing, QA, or recovery auditing ideally in a DRG/Clinical Validation is a plus. Work hours: Monday - Friday 8:00am- 5:00pm Remote position

Requirements

At least 3 years clinical nursing experience, with at least 1 year of managed care experience in the specific programs supported by the plan such as utilization review, medical claims review, long-term services and supports (LTSS), or other specific program experience as needed (such as specialties in: surgical, ob/gyn, home health, pharmacy, etc.), or equivalent combination of relevant education and experience.
Registered Nurse (RN). License must be active and unrestricted in state of practice.
Experience demonstrating knowledge of ICD-9, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC).
Experience demonstrating knowledge of Centers for Medicare and Medicaid Services (CMS) guidelines, MCG, InterQual or other medically appropriate clinical guidelines, Medicaid, Medicare, CHIP and Marketplace, applicable state regulatory requirements, including ability to easily access and interpret these guidelines.
Critical-thinking skills.
Ability to interact effectively with clinical leaders and peers across the organization.
Strong verbal and written communication skills.
Microsoft Office suite/applicable software program(s) proficiency.

Nice To Haves

Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ) or other health care coding or management certification.
2+ years in claims auditing, QA, or recovery auditing ideally in a DRG/Clinical Validation

Responsibilities

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.