Clinical Appeals Nurse (RN)

We are seeking a dedicated and compassionate Clinical Appeals Nurse (RN) to join our team at Molina Healthcare. As a Clinical Appeals Nurse, you will be responsible for reviewing and resolving denied or rejected medical claims through thorough research and appeals processes. Your expertise and attention to detail will play a crucial role in advocating for our members and ensuring they receive the necessary healthcare services. This position requires a candidate with a strong clinical background, excellent communication skills, and a passion for making a positive impact on the lives of others. If you are a driven and empathetic RN with a desire to work for a company that values patient care above all else, we encourage you to apply for this fulfilling opportunity.

1. Review and resolve denied or rejected medical claims through thorough research and appeals processes.
2. Advocate for members by ensuring they receive necessary healthcare services.
3. Conduct detailed reviews of medical records and other relevant documentation to support appeal cases.
4. Collaborate with healthcare providers, insurance companies, and other stakeholders to gather necessary information for appeals.
5. Utilize clinical expertise and knowledge of medical guidelines to evaluate the medical necessity of denied claims.
6. Prepare and submit thorough and timely appeals to insurance companies or other entities as needed.
7. Communicate effectively with members, providers, and internal teams regarding appeal status and outcomes.
8. Maintain accurate and organized documentation of appeal cases.
9. Stay updated on industry regulations and changes to appeal processes and guidelines.
10. Participate in team meetings and provide input on process improvements and best practices.
11. Provide support and guidance to other team members as needed.
12. Adhere to all company policies and procedures, as well as ethical and legal standards.
13. Display compassion and empathy towards members and their healthcare needs.
14. Collaborate with other departments, such as Utilization Management and Care Management, to ensure coordinated and effective appeals processes.
15. Uphold Molina Healthcare's commitment to providing quality and affordable healthcare to its members.

According to JobzMall, the average salary range for a Clinical Appeals Nurse (RN) in Louisville, KY, USA is $63,000 - $75,000 per year. However, salary can vary depending on factors such as experience, education, and specific job responsibilities.

Molina Healthcare is a managed care company headquartered in Long Beach, California, United States. The company provides health insurance to individuals through government programs such as Medicaid and Medicare.