Medical Review Nurse (RN)

About This Role

This role supports medical claim and internal appeals review activities, ensuring alignment with regulatory requirements and clinical guidelines. The Medical Review Nurse contributes to providing quality and cost-effective member care by reviewing and reevaluating medical claims and associated records.

Responsibilities

• Facilitate clinical/medical reviews of retrospective medical claim reviews, medical claims, and previously denied cases to ensure medical necessity and appropriate/accurate billing and claims processing
• Reevaluate medical claims and associated records by applying advanced clinical knowledge and regulatory requirements to assess the appropriateness of services, length of stay, level of care, and inpatient readmissions
• Validate member medical records and claims submitted/correct coding to ensure appropriate reimbursement to providers
• Resolve escalated complaints regarding utilization management and long-term services and supports (LTSS) issues
• Identify and report quality of care issues
• Assist with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, and appropriate level of care, making decisions pertinent to clinical experience
• Prepare and present cases representing Molina for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings
• Review medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions
• Supply criteria supporting all recommendations for denial or modification of payment decisions
• Serve as a clinical resource for utilization management, CMOs, physicians, and member/provider inquiries/appeals

Requirements

• 2+ years clinical nursing experience
• 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
• Active and unrestricted Registered Nurse (RN) license in state of practice
• 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
• Attention to detail
• Critical-thinking and active listening skills
• Microsoft Office suite proficiency

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.

Nice to Have

• Certified Clinical Coder (CCC)
• Certified Medical Audit Specialist (CMAS)
• Certified Case Manager (CCM)
• Certified Professional Healthcare Management (CPHM)
• Certified Professional in Healthcare Quality (CPHQ)
• Other healthcare certifications
• Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics
• Billing and coding experience

Skills

* Required skills