RN UM Clinical Appeals Nurse Remote

JOB DESCRIPTION Job Summary The Clinical Appeals Nurse (RN) 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. Candidates with UM and Appeals experience are highly preferred Work hours: Monday- Friday 8:00am - 5:00pm Central time Remote position Essential Job Duties u2022 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. u2022 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. u2022 Applies appropriate criteria on PAR and Non-PAR (contracted and non-contracted) cases and with Marketplace EOCs (Evidence of Coverage). u2022 Reviews medically appropriate clinical guidelines and other appropriate criteria with chief medical officer on denial decisions. u2022 Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. u2022 Identifies and reports quality of care issues. u2022 Prepares and presents cases in conjunction with the chief medical officer for administrative law judge pre-hearings, state insurance commission, and meet and confers. u2022 Represents Molina and presents cases effectively to judicial fair hearing officer during fair hearings as may be required. u2022 Serves as a clinical resource for utilization management, chief medical officer, physicians, and member/provider inquiries/appeals. u2022 Provides training, leadership and mentoring for less experienced appeals nurses and administrative team members. Required Qualifications u2022 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. u2022 Registered Nurse (RN). License must be active and unrestricted in state of practice. u2022 Experience demonstrating knowledge of ICD-9, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). u2022 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. u2022 Critical-thinking skills. u2022 Ability to interact effectively with clinical leaders and peers across the organization. u2022 Strong verbal and written communication skills. u2022 Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications u2022 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. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. 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.

Created: 2025-11-17