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REMOTE CLINICAL APPEALS NURSE (RN) TEXAS AND NEW MEXICO

Represent Molina and present cases effectively to Judicial Fair Hearing Officer during Fair Hearings.
AustinHouston
Senior
$54,373.27 - $117,808.76 USD per year
1 week ago
Molina Healthcare

Molina Healthcare

Molina Healthcare is a FORTUNE 500, multi-state health care organization.

1 Similar Job at Molina Healthcare

✨ About The Role

- Responsible for making appropriate clinical decisions for appeals outcomes within compliance standards - Conducts clinical/medical reviews of denied cases for appeals requests - Re-evaluates medical claims by applying clinical knowledge, regulatory requirements, and guidelines to assess appropriateness of service provided - Prepares and presents cases for Administrative Law Judge pre-hearings and State Insurance Commission - Serves as a clinical resource for Utilization Management, Chief Medical Officer, Physicians, and Member/Provider Inquiries/Appeals

⚡ Requirements

- Experienced Registered Nurse with a background in Utilization Review/Utilization Management and knowledge of Interqual/MCG guidelines - Strong analytical skills and ability to multitask effectively in a remote work environment - Ability to independently re-evaluate medical claims and apply advanced clinical knowledge to assess appropriateness of services provided - Skilled in resolving escalated complaints and identifying quality of care issues - Previous experience in training, leadership, and mentoring for clinical staff
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REMOTE CLINICAL APPEALS NURSE (RN) TEXAS AND NEW MEXICO
AustinHouston
$54,373.27 - $117,808.76 USD per year
Registered Nurse
About Molina Healthcare
Molina Healthcare is a FORTUNE 500, multi-state health care organization.