Lead, Medical Review Nurse (RN)

Molina Healthcare•Long Beach, CA

About The Position

Provides lead level 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.

Requirements

At least 4 years clinical nursing experience, including broad knowledge of utilization management, medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology, and 4 years claims auditing, quality assurance, and/or recovery auditing experience, ideally in a DRG/clinical validation setting, and 3 years utilization review and/or medical claims experience, or equivalent combination of relevant education and experience.
Registered Nurse (RN). License must be active and unrestricted in state of practice.
Requires strong knowledge in coding: diagnosis related group (DRG), ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC).
Extensive background in either facility-based nursing and/or inpatient coding, and deep understanding of reimbursement guidelines.
Ability to collaborate effectively with clinical leaders and peers across the organization.
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.
CommonLook proficiency
Strong verbal and written communication skills.
Microsoft Office suite proficiency (including Excel), and applicable software program(s) proficiency.

Nice To Haves

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.
Experience and knowledge of MCG criteria and MCQA
Experience in Managed Care

Responsibilities

Key contributor in enhancement of current processes, training, audits, and production management related to claims review and settlement processes.
Develops tools and process improvements based on identified trends to ensure that claims are settled in a timely fashion and in accordance with quality reviews.
Identifies potential claims outside of current concepts where additional opportunities may be available; suggests and develops high-quality, high-value concepts and/or process improvements and tools.
Audits inpatient medical records for generation of high-quality claims payments, ensuring payment integrity.
Performs clinical reviews of medical records and other documentation to evaluate coding issues and diagnosis-related group (DRG) assignment accuracy.
Integrates medical chart coding principles, clinical guidelines, and objectivity in performance of medical audit activities; draws on clinical guidelines and industry knowledge to substantiate conclusions.
Influences and engages team members across functional teams to achieve results.
Facilitates and provides support to other medical claim/internal appeals review team members (i.e., development, training, and audits).
Demonstrates ownership of medical claim/internal appeals review job aids to ensure accuracy.
Assists in the creation of policies and procedures and standard operating procedures (SOPs), to ensure program compliance.
Escalates issues to medical directors, health plan leadership/team members, claims team members, and other functional leaders/team members as applicable.
Facilitates updates or changes to ensure coding guidelines are established and followed within the health information management (HIM) department and according to National Correct Coding Initiatives (NCCI), and other relevant coding guidelines.
Ensures alignment with Centers for Medicare and Medicaid Services (CMS) guidelines in relation to multiple procedure payment reductions and other mandated pricing methodologies.
Supports the development of auditing rules within software components to meet CMS regulatory mandates.
Utilizes Molina proprietary auditing systems with a high-level of proficiency to make audit determinations, generate audit letters and train team members.