Job Description

**JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct clinical decisions for appeals outcomes within compliance standards. This position will support our Claims business. The candidate must have an unrestricted RN license. This position will performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing. Identifies and reports quality of care issues. Assists with Complex Claim review including DRG Validation, Itemized Bill Review, Appropriate Level of Care, Inpatient Readmission, and any opportunity identified by the Payment Integrity analytical team; requires decision making pertinent to clinical experience. Documents clinical review summaries, bill audit findings and audit details in the database. Provides supporting documentation for denial and modification of payments decisions. Remote position Work hours: Monday - Friday Monday 8:00am - 5:00pm (occasional weekend per business need) Unrestricted RN licensure **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. + 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. + Reviews medically appropriate clinical guidelines and other appropriate criteria with Medical Directors on denial decisions. + Supplies criteria supporting all recommendations for denial or modification of payment decisions. + Serves as a clinical SME for Utilization Management, Chief Medical Officers, Physicians, and Member/Provider Inquiries/Appeals. + Provides training and support to clinical peers. + Identifies and refers members with special needs to the appropriate Molina Healthcare program per policy/protocol. + Resolves escalated complaints regarding PI Medical Claim Review initial and dispute reviews. + Analytical review and validation as assigned + Policy and procedure updates + Support team lead with drafting Job aids development, research, coverage in absence and updates or sharing process improvement recommendations. + Designated SME to test new applications and software updates on current applications + Understanding of overall operational processes as it relates to PI MCR to resolve issues + General knowledge of Healthcare Administration **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, Medicaid, 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. **Preferred License, Certification, Association** Any one or more of the following: + Active and unrestricted Certified Clinical Coder + Certified Medical Audit Specialist + Certified Case Manager + Certified Professional Healthcare Management + Certified Professional in Healthcare Quality + other healthcare certification To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. 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 *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Tags

Work experience placement, Remote job, Monday to Friday,

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