Job ID 2021674
Responsible for leading, organizing and directing the Daily and weekly activities of the Clinical Grievance and Appeals Unit. Is responsible for overviewing the process of member appeals, complaints ensuring completion in accordance with the Molina standards and requirements established by the Centers for Medicare and Medicaid and State regulatory agencies.
- Operational Efficiency: Assists in implementing clinical task in accordance with regulatory, contract standards and accreditation compliance.
- Functions as clinical staff lead within the MCS- Appeals and Grievance Department. Responsibilities include supervisory capabilities and oversight of daily administrative functions, including work quality
- Resolves problems and complaints that may arise in day-to-day operations that involve clinical staff. Communicates findings to the Manager, Molina Clinical Services.
- Training: Assists in the coordination of orienting and training staff, new and existing, to ensure maximum efficiency and productivity, program implementation, and service excellence.
- Oversight: Assists with staff Performance Appraisals, ongoing monitoring of performance, and application of protocols and guidelines. Collaborates with and keeps the Manager, Molina Clinical Services, apprised of operational issues, staffing, resources, system, and program needs.
- Assists with coordination and reporting of department Productivity and ongoing clinical reports, as assigned.
Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred.
- 3-5 years clinical nursing experience, with 1-3 years Managed Care Experience in the specific programs supported by the plan such as Utilization Review, Medical Claims Review, Long Term Service and Support, or other specific program experience as needed or equivalent experience (such as specialties in: surgical, Ob/Gyn, home health, pharmacy, etc.).
- Experience demonstrating knowledge of ICD-9, CPT coding and HCPC.
- Experience demonstrating knowledge of CMS Guidelines, MCG, InterQual or other medically appropriate clinical guidelines, Medicaid, Medicare, CHIP and Marketplace, applicable State regulatory requirements, including the ability to easily access and interpret these guidelines.
Required License, Certification, Association
Active, unrestricted State Registered Nursing (RN) license in good standing.
Bachelor’s Degree in Nursing
5+ years Clinical Nursing experience, including hospital acute care/medical experience.
Preferred License, Certification, Association
- 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.
Pay Range: $63,133-123,110 annually
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Job Type: Full TimePosting Date: 08/09/2023
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