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Clinical Appeals Specialist
2 months ago
Molina Healthcare is seeking a skilled Clinical Appeals Specialist to join our team. As a Clinical Appeals Specialist, you will be responsible for making informed clinical decisions to ensure that our members receive the best possible care.
Key Responsibilities- Clinical Review and Decision Making: Conduct thorough reviews of medical claims and associated records to determine the appropriateness of service provided, length of stay, and level of care.
- Appeals and Grievances: Resolve escalated complaints regarding Utilization Management and Long-Term Services & Supports issues, and identify and report quality of care issues.
- Collaboration and Communication: Work closely with the Chief Medical Officer, physicians, and other healthcare professionals to ensure that our members receive the best possible care.
- Training and Development: Provide training, leadership, and mentoring to less experienced appeal staff.
- Education: Graduate from an Accredited School of Nursing. Bachelor's degree in Nursing preferred.
- Experience: 3-5 years clinical nursing experience, with 1-3 years Managed Care Experience in the specific programs supported by the plan.
- Licensure: Active, unrestricted State Registered Nursing (RN) license in good standing.
- Education: Bachelor's Degree in Nursing.
- Experience: 5+ years Clinical Nursing experience, including hospital acute care/medical experience.
- Certifications: Any one or more of the following: Certified Clinical Coder, Certified Medical Audit Specialist, Certified Case Manager, Certified Professional Healthcare Management, Certified Professional in Healthcare Quality, or other healthcare certification.
Molina Healthcare is a leading healthcare company dedicated to providing quality healthcare services to our members. We are committed to making a positive impact in the lives of our members and the communities we serve.
