Medical Review Nurse (RN)

About This Role

This role provides support for medical claim and internal appeals review activities, ensuring alignment with regulatory requirements, Molina policies, and clinical guidelines. The Medical Review Nurse contributes to the strategy for providing quality and cost-effective member care by performing clinical/medical reviews.

Responsibilities

• Facilitate clinical/medical reviews of retrospective medical claim reviews, medical claims, and previously denied cases
• Reevaluate medical claims and associated records by applying advanced clinical knowledge and regulatory guidelines
• Validate member medical records and claims submitted/correct coding to ensure appropriate reimbursement
• 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 DRG validation, itemized bill review, and appropriate level of care
• 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 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 and medical inquiries/appeals

Requirements

• At least 2 years clinical nursing experience
• At least 1 year of utilization review, medical claims review, LTSS, claims auditing, medical necessity review and/or coding 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
• Common look proficiency
• Effective verbal and written communication skills
• Microsoft Office suite and applicable software program(s) 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)
• Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics
• Billing and coding experience

Skills

* Required skills