Clinical Appeals Nurse (RN): Texas and New Mexico REMOTE

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Clinical Appeals is responsible for making appropriate and correct clinical decisions for appeals outcomes within compliance standards.

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.