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Author Health
Miami, Florida
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Molina Healthcare
Spokane, Washington
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United States - Nationwide
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Clinical Appeals Nurse (RN)
JOB DESCRIPTIONJob SummaryClinical Appeals is responsible for making appropriate and correct clinical decisions for appeals outcomes within compliance standards.KNOWLEDGE/SKILLS/ABILITIES The Clinical Appeals Nurse (RN) performs clinical/medical reviews of previously denied cases in which a formal appeals request has been made or upon request by another Molina department to reduce the likelihood of a formal appeal being submitted. Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judg
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