Advanced Practice Nurse Practitioner

About the Role

Advanced Practice Nurse Practitioner at Molina Healthcare in Rio Rancho, NM. Benefits: health benefits.

Key Responsibilities

• Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.
• Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review and manages the denial process.
• Ensures that medical protocols and rules of conduct for plan medical personnel are followed.
• Develops and implements plan medical policies.
• Provides implementation support for quality improvement activities.
• Collaborates with contracting department in contract negotiations.

Requirements

• Attends or chairs committees as required such as credentialing, Pharmacy and Therapeutics (P&T) and others as directed by the chief medical officer.
• Required Qualifications
• Advanced Practice Registered Nurse (APRN) license. License must be active and unrestricted in the state of practice.
• Ability to maintain attendance to support required quality and quantity of work.
• Board certification (primary care preferred).
• Peer review, medical policy/procedure development, and/or provider contracting experience.

Benefits & Compensation

• Ability to work independently, with minimal supervision and demonstrate self-motivation.
• Ability to maintain confidentiality and comply with health insurance portability and accountability act (HIPAA).
• Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
• Ability to work independently, with minimal supervision and demonstrate self-motivation
• Ability to maintain confidentiality and comply with health insurance portability and accountability act (HIPAA)