Nurse

Job Summary

Join our dedicated team as a Nurse Reviewer, where you will play a crucial role in supporting medical claim and internal appeal reviews. Your expertise will ensure compliance with relevant state and federal regulations, Molina policies, and clinical guidelines, all while contributing to a strategy focused on delivering high-quality and cost-effective care for our members.

Key Responsibilities

• Lead comprehensive clinical reviews of retrospective medical claims, appeals, and previously denied cases to confirm medical necessity and correct billing practices.
• Evaluate medical claims and related records using advanced clinical knowledge to assess service appropriateness, length of stay, level of care, and readmissions.
• Validate medical records and claims to ensure accurate coding and appropriate reimbursement for providers.
• Address escalated complaints concerning utilization management and long-term services and supports (LTSS) issues.
• Identify and report quality of care concerns.
• Assist with complex claims reviews, including DRG validation, itemized bill reviews, and opportunities identified by the payment integrity analytical team.
• Prepare and present cases for administrative law judge pre-hearings and state insurance commissions alongside the chief medical officer.
• Review clinical guidelines regularly with medical directors regarding denial decisions.
• Support all recommendations for denial or modification of payment decisions with solid criteria.
• Act as a clinical resource for utilization management, CMOs, physicians, and address member/provider inquiries.
• Provide training and mentorship to clinical colleagues.
• Identify and refer members with special needs to appropriate Molina programs per policy and protocols.

Qualifications

Required:

• A minimum of 2 years of clinical nursing experience, including at least 1 year in utilization review, medical claims review, or related fields.
• Current and unrestricted Registered Nurse (RN) license in your state.
• Knowledgeable in ICD-10, CPT coding, and HCPC.
• Experience working within relevant regulations.
• Strong analytical, problem-solving, and decision-making abilities.
• Excellent organizational and time-management skills.
• Heightened attention to detail.
• Effective critical thinking and listening capabilities.
• Proficient in Microsoft Office and relevant software.

Preferred:

• Relevant certifications such as Certified Clinical Coder (CCC) or Certified Professional Healthcare Management (CPHM).
• Experience in critical care, emergency medicine, or pediatrics.
• Background in billing and coding.

If you're passionate about making a difference and meet the qualifications, we encourage you to apply to join Molina Healthcare, an Equal Opportunity Employer (EOE) M/F/D/V. We offer a competitive benefits package.

Pay Range: $29.05 - $67.97 per hour. Note that actual compensation may vary based on geographic location, work experience, education, and skills.