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.

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