REMOTE CLINICAL APPEALS NURSE (RN) TEXAS AND NEW MEXICO

✨ 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
                            

+ Show Original Job Post

Suggest a correction

REMOTE CLINICAL APPEALS NURSE (RN) TEXAS AND NEW MEXICO

AustinHouston

$54,373.27 - $117,808.76 USD per year

Registered Nurse

Apply to job

About Molina Healthcare

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