Clinical Appeals Nurse (RN)

Molina
NY, AZ
Category Legal
Job Description
Molina Healthcare is seeking a Clinical Appeals Nurse (RN) to make appropriate clinical decisions for appeals outcomes. The role involves independently reviewing medical claims, applying clinical knowledge and regulations, and presenting cases to Legal Appeals. The ideal candidate will be responsible for resolving escalated complaints and providing clinical support to Utilization Management and Legal teams.

Requirements

  • Graduate from an Accredited School of Nursing.
  • Bachelor's degree in Nursing preferred.
  • 3-5 years clinical nursing experience.
  • 1-3 years Managed Care Experience (Utilization Review, Medical Claims Review, etc.)
  • Experience with ICD-9, CPT, and HCPC coding.
  • Experience with CMS Guidelines, MCG, InterQual, and other clinical guidelines.
  • Active State Registered Nursing (RN) license.
  • Excellent clinical knowledge & understanding of regulatory requirements.

Benefits

  • Competitive benefits package
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