Talent.com
Medical Appeal Nurse
Medical Appeal NurseMolina Healthcare • Milwaukee, WI, United States
[error_messages.no_longer_accepting]
Medical Appeal Nurse

Medical Appeal Nurse

Molina Healthcare • Milwaukee, WI, United States
[job_card.variable_days_ago]
[job_preview.job_type]
  • [job_card.full_time]
[job_card.job_description]

Job Summary

Join our team as a Medical Appeal Nurse, where you'll play a critical role in supporting medical claim and internal appeals reviews. Your expertise will be essential in ensuring compliance with state and federal regulations, Molina policies, and clinical guidelines, all while contributing to the mission of providing quality, cost-effective care for our members.

Key Responsibilities

  • Lead clinical reviews of retrospective medical claims, including previously denied cases, to assess medical necessity and ensure accurate billing and claims processing.
  • Utilize your advanced clinical knowledge to reevaluate medical claims, interpreting regulations, Molina policies, and your clinical experience to determine the appropriateness of services provided.
  • Ensure correct coding and reimbursement for providers by validating member medical records and claims.
  • Address escalated complaints regarding utilization management and long-term services and supports (LTSS) issues.
  • Identify and report any quality of care concerns that arise during reviews.
  • Assist with complex claim reviews such as diagnosis-related group (DRG) validation, inpatient readmissions, and collaborate with the payment integrity analytical team to enhance decision-making.
  • Prepare and represent cases alongside the chief medical officer for administrative law judge pre-hearings and state insurance commission hearings.
  • Collaborate with medical directors to review medically appropriate clinical guidelines and support denial decision-making.
  • Provide criteria and justifications for all recommendations regarding payment decisions.
  • Act as a clinical resource for utilization management, CMOs, doctors, and inquiries from members or providers.
  • Facilitate training and support for clinical peers to improve overall performance.
  • Identify members with special needs and refer them to appropriate Molina programs as per guidelines.

Qualifications

Required:

  • A minimum of 2 years of clinical nursing experience, including at least 1 year in utilization review or medical claims review.
  • Current, active, and unrestricted RN license in your state of practice.
  • Proficiency in ICD-10, CPT coding, and HCPC knowledge.
  • Experience with state and federal regulations in healthcare.
  • Strong analytical, problem-solving, and decision-making skills.
  • Excellent organizational and time-management abilities, with a keen attention to detail.
  • Critical-thinking skills combined with active listening capabilities.
  • Proficient in Microsoft Office Suite and relevant software programs.

Preferred:

  • Certifications such as Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), or Certified Professional in Healthcare Quality (CPHQ).
  • Experience in critical care, emergency medicine, medical/surgical nursing, or pediatrics.
  • Background in billing and coding is an advantage.

To all current Molina employees: If you are interested, please apply via the Internal Job Board. We offer a competitive benefits and compensation package, and we are proud to be an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $56.64 / HOURLY. *Compensation may vary based on geographic location, work experience, education, and skill level.

[job_alerts.create_a_job]

Medical Appeal Nurse • Milwaukee, WI, United States

[internal_linking.similar_jobs]

Medical Surgical Unit - Travel Registered Nurse

Trusted HealthThiensville, WI, United States
[job_card.full_time]

Trusted is seeking an experienced nurse for this exciting travel nursing assignment.Trusted has streamlined the travel nursing experience by enabling nurses to apply directly to jobs without the ne...[internal_linking.show_more]

 • [job_card.promoted]

Physician - Hospital Medicine - Froedtert Pleasant Prairie Hospital

VituityPleasant Prairie, WI, United States
[job_card.full_time]

Pleasant Prairie, WI – Seeking Hospital Medicine Physicians.Join the Physician Partnership Where You Can Increase Your Impact.Vituity’s ownership model provides autonomy, local control, and a natio...[internal_linking.show_more]

 • [job_card.promoted]

Medical Assistant Certified/Registered - AM

Amergis Healthcare StaffingUnion Grove, WI, United States
[job_card.full_time]

Amergis Healthcare Staffing is seeking a Medical Assistant responsible for performing duties under the direction of a physician to assist in the examination and treatment of patients.High School di...[internal_linking.show_more]

 • [job_card.promoted]

Medical Surgical

Aya HealthcarePleasant Prairie, WI, United States
[job_card.full_time]

Certified Nursing Assistant (CNA) Med Surg.Under the direction of the Registered Nurse (RN), the Certified Nursing Assistant (CNA) performs tasks for patients Activities of Daily Living to promote ...[internal_linking.show_more]

 • [job_card.promoted]

Medical Assistant

ADVENTMilwaukee, WI, United States
[job_card.full_time]

Rediscover Purpose with ADVENT.At ADVENT, we do healthcare differently.We focus on innovative solutions and patient-first care.If you're driven, creative, and ready to make an impact, join us.Locat...[internal_linking.show_more]

 • [job_card.promoted]

WI Facility Needs a Locum Tenens Interventional Cardiologist

HealthEcareers - ClientMount Pleasant, WI, USA
[job_card.full_time]

CompHealth exists to make the locums process easier.Not only will we search for jobs that fit your interests, we'll be here to handle all the details like credentialing, housing, travel arrangement...[internal_linking.show_more]

 • [job_card.promoted]

Medical Assistant

ActalentPleasant Prairie, WI, United States
[job_card.full_time]

We are seeking a dedicated and skilled Medical Assistant to join our healthcare team.Under the direction of the clinic supervisor, the Medical Assistant will be responsible for receiving patients, ...[internal_linking.show_more]

 • [job_card.promoted]

Outpatient Registered Nurse - RN

Fresenius Medical CareWest Allis, Wisconsin, US
[job_card.full_time]

Career Advancement Program (CAP) to advance your nephrology career from novice to expert.The professional registered nurse Outpatient RN CAP 1 is an entry level designation into the Clinical Advanc...[internal_linking.show_more]

 • [job_card.promoted]

Anesthesiology - Certified Registered Nurse Anesthetist

HealthEcareers - ClientPleasant Prairie, WI, USA
[job_card.permanent]

Are you a CRNA searching for your next locum tenens opportunity?.This position with one of VISTA's healthcare partners in.Monday‐Friday surgical days with weekday and weekend call.Hospital‐based an...[internal_linking.show_more]

 • [job_card.promoted]

Surrogates Start at $55K–$75K+ | $1,200 Bonus + $11K Pre-Pregnancy Payout

Physician's SurrogacyMount Pleasant, WI, US
[job_card.full_time] +2

Surrogates Start at $60K$75K+ $1,250 Bonus + $11K Pre-Pregnancy Payout.Looking for a high-paying opportunity with real support and no upfront costs?.Become a Surrogate and earn up to.All expenses p...[internal_linking.show_more]

 • [job_card.promoted]

Travel Med Surg RN

Fusion Medical StaffingPleasant Prairie, Wisconsin, US
[job_card.full_time]

The experience expected from applicants, as well as additional skills and qualifications needed for this job are listed below.Facility in Pleasant Prairie, Wisconsin.Fusion Medical Staffing is seek...[internal_linking.show_more]

 • [job_card.promoted] • [job_card.new]

Medical Assistant

MedixPleasant Prairie, WI, United States
[job_card.full_time]

Medix is seeking a Medical Assistant for a full time role within a clinic in Pleasant Prairie, WI! A great opportunity to work within a reputable health system and team!.Prepare exam rooms and comp...[internal_linking.show_more]

 • [job_card.promoted]

Medical Assistant (MA) - General Surgery Clinic

Advocate Health CarePleasant Prairie, WI, United States
[job_card.full_time]

Adheres to Medical Assistant scope of practice, follows all policies and procedures, and maintains training and competency based on area of specialty when providing patient care.Performs rooming/vi...[internal_linking.show_more]

 • [job_card.promoted]

Certified Registered Nurse Anesthetist (CRNA)

HealthEcareers - ClientPleasant Prairie, WI, USA
[job_card.full_time]

Job Description & Requirements.Certified Registered Nurse Anesthetist (CRNA).StartDate: ASAP Available Shifts: Day 8;9 Pay Rate: $206.This facility is seeking a Certified Registered Nurse Anestheti...[internal_linking.show_more]

 • [job_card.promoted]

Anesthesiology - Certified Registered Nurse Anesthetist

VISTA Staffing SolutionsPleasant Prairie, US
[job_card.permanent]

Are you a CRNA searching for your next locum tenens opportunity?.This position with one of VISTA's healthcare partners in.Monday‐Friday surgical days with weekday and weekend call.Hospital‐based an...[internal_linking.show_more]

 • [job_card.promoted]

Certified Registered Nurse Anesthetist (CRNA)

AMN HealthcarePleasant Prairie, US
[job_card.full_time]

Job Description & Requirements.Certified Registered Nurse Anesthetist (CRNA).StartDate: ASAP Available Shifts: Day 8;9 Pay Rate: $206.This facility is seeking a Certified Registered Nurse Anestheti...[internal_linking.show_more]

 • [job_card.promoted]

Medical Assistant Certified/Registered - Employee Health

SSM Health Rehabilitation HospitalMilwaukee, WI, United States
[job_card.full_time]

It's more than a career, it's a calling.This is a PRN role that will be needed mostly on Monday's to assist with our new hires.Provides assistance with the examination and treatment of patients und...[internal_linking.show_more]

 • [job_card.promoted]

Medical Review Nurse (post appeal nurse - IL preferred)

Molina HealthcareMilwaukee, WI, United States
[job_card.full_time]

Job DescriptionJob SummaryProvides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies a...[internal_linking.show_more]