Work From Home Jobs (Remote) In Starkville @Onlinejob247 ( Clinical Appeals Nurse (RN) )
Company Name: Molina Healthcare
Post Name: Clinical Appeals Nurse (RN)
Qualification: Graduation
Industry: Private
Employment Type: Full Time
Work Hours: 8 Hours
Salary: $20-30/hour
Location: Mississippi, USA
Full Description:
Scientific Appeals is accountable for making suitable and correct clinical decisions for appeals consequences within compliance requirements.
Work From Home Jobs (Remote) In Starkville @Onlinejob247 ( Clinical Appeals Nurse (RN) )
Expertise/abilties/capabilities
- The clinical Appeals Nurse (RN) plays medical/clinical reviews of previously denied instances in which a formal appeals request has been made or upon request through another Molina branch to lessen the likelihood of a proper enchantment being submitted.
- Independently re-evaluates medical claims and associated records by means of making use of advanced clinical information, know-how of all relevant and applicable Federal and kingdom regulatory requirements and hints, knowledge of Molina guidelines and tactics, and character judgment and enjoy to evaluate the appropriateness of service provided, length of live and degree of care.
- Applies suitable criteria on PAR and Non-PAR (gotten smaller and non-shriveled) instances and with market EOCs (evidence of insurance).
- Evaluations medically suitable medical tips and different appropriate standards with leader clinical Officer on denial selections.
- Resolves escalated proceedings concerning usage management and long-time period offerings & helps problems.
- Identifies and reports satisfactory of care troubles.
- Prepares and presents cases together with the chief clinical Officer for Administrative regulation decide pre-hearings, country coverage fee, and Meet and Confers.
- Represents Molina and offers instances successfully to Judicial fair listening to Officer in the course of honest Hearings as may be required.
- Serves as a medical useful resource for utilization control, leader scientific Officer, Physicians, and Member/issuer Inquiries/Appeals.
- Provides education, management and mentoring for much less skilled enchantment LVN, RN and administrative body of workers.
Required education
- Graduate from an authorized college of Nursing. Bachelor's diploma in Nursing desired.
Work From Home Jobs (Remote) In Starkville @Onlinejob247 ( Clinical Appeals Nurse (RN) )
Required revel in
- Three-5 years medical nursing experience, with 1-3 years managed Care experience within the precise packages supported by means of the plan inclusive of usage review, scientific Claims overview, long time provider and guide, or other particular application experience as wanted or equivalent revel in (inclusive of specialties in: surgical, Ob/Gyn, domestic fitness, pharmacy, etc.).
- Enjoy demonstrating expertise of ICD-9, CPT coding and HCPC.
- Experience demonstrating information of CMS pointers, MCG, InterQual or different medically suitable scientific suggestions, Medicaid, Medicare, CHIP and marketplace, relevant kingdom regulatory requirements, together with the potential to without difficulty get right of entry to and interpret these recommendations.
Required License, Certification, association
- Active, unrestricted nation Registered Nursing (RN) license in top status.
Favored education
- Bachelor's degree in Nursing
Favored experience
- Five+ years clinical Nursing enjoy, along with hospital acute care/scientific revel in.
Desired License, Certification, association
Any one or extra of the following:
- Lively and unrestricted certified scientific Coder
- Certified medical Audit specialist
- Licensed Case manager
- Licensed professional Healthcare management
- Certified professional in Healthcare nice
- Different healthcare certification
Work From Home Jobs (Remote) In Starkville @Onlinejob247 ( Clinical Appeals Nurse (RN) )
