Medical Review Nurse (RN)

JOB DESCRIPTION

Looking for a RN that has a current active unrestricted

license

This a remote role and can sit anywhere

within the United States.

Work Schedule

Monday to Friday - operation hours 6 AM to 6 PM (Team will work on

set schedule)

Looking for a RN with

experience with appeals, claims review, and medical

coding.

Job Summary

Provides support for medical claim and

internal appeals review activities - ensuring alignment with

applicable state and federal regulatory requirements, Molina

policies and procedures, and medically appropriate clinical

guidelines. Contributes to overarching strategy to provide quality

and cost-effective member care.

ESSENTIAL JOB

DUTIES :

Facilitates clinical / medical

reviews of retrospective medical claim reviews, medical claims and

previously denied cases in which an appeal has been made, or is

likely to be made, to ensure medical necessity and

appropriate / accurate billing and claims

processing.

Reevaluates medical claims and associated

records by applying advanced clinical knowledge, knowledge of

relevant and applicable state and federal regulatory requirements

and guidelines, knowledge of Molina policies and procedures, and

individual judgment and experience to assess the appropriateness of

services provided, length of stay, level of care, and inpatient

readmissions.

Validates member medical records and claims

submitted / correct coding, to ensure appropriate reimbursement to

providers.

Resolves escalated complaints regarding

utilization management and long-term services and supports (LTSS)

issues.

Identifies

and reports quality of care issues.

Assists with complex claim review including

diagnosis-related group (DRG) validation, itemized bill review,

appropriate level of care, inpatient readmission, and any

• opportunities identified by the payment integrity analytical team;

makes decisions and recommendations pertinent to clinical

experience.

Prepares

and presents cases representing Molina, along with the chief

medical officer (CMO), for administrative law judge pre-hearings,

state insurance commissions, and judicial fair hearings.

Reviews medically appropriate clinical

guidelines and other appropriate criteria with medical directors on

denial decisions.

Supplies criteria supporting all

recommendations for denial or modification of payment

decisions.

Serves as

a clinical resource for utilization management, CMOs, physicians

and member / provider

inquiries / appeals.

Provides training and support to clinical

peers.

Identifies and refers members with special

needs to the appropriate Molina program per applicable

policies / protocols.

REQUIRED

QUALIFICATIONS :

At least 2 years clinical nursing

experience, including at least 1 year of utilization review,

medical claims review, long-term services and supports (LTSS),

claims auditing, medical necessity review and / or coding experience,

or equivalent combination of relevant education and

experience.

Registered Nurse (RN). License must be active

and unrestricted in state of

practice.

Experience demonstrating knowledge of ICD-10,

Current Procedural Technology (CPT) coding and Healthcare Common

Procedure Coding (HCPC).

Experience working within applicable state,

federal, and third-party regulations.

Analytic, problem-solving, and

decision-making skills.

Organizational

and time-management skills.

Critical-thinking and active listening

skills.

Common

look proficiency.

Effective verbal and written communication

skills.

Microsoft

Office suite and applicable software program(s)

proficiency.

PREFERRED

QUALIFICATIONS :

Certified Clinical Coder (CCC),

Certified Medical Audit Specialist (CMAS), Certified Case Manager

(CCM), Certified Professional Healthcare Management (CPHM),

Certified Professional in Healthcare Quality (CPHQ), or other

health care certifications.

Nursing experience in critical care,

emergency medicine, medical / surgical or

pediatrics.

Billing and coding

experience.

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.

Pay Range : $29.05 - $67.97 / HOURLY

geographic location, work experience, education and / or skill

level.