Medical Review Nurse (RN)- Post Appeals (must be licensed in Illinois)

Molina Healthcare•Long Beach, CA

About The Position

The Medical Review Nurse uses clinical knowledge and experience to review medical documentation for medical necessity, appropriate level of care, and accurate coding. The role applies MCG/InterQual criteria, state and federal guidelines, billing and coding regulations, and Molina policies. It also validates whether member medical records and submitted claims support correct coding and appropriate provider reimbursement. The position handles prospective, retrospective, and concurrent appeals reviews involving denied prior authorizations, including standard and expedited inpatient, outpatient, and pharmaceutical cases. It also conducts retrospective medical claim reviews and reviews appealed or potentially appealed cases. The nurse assesses the appropriateness of services, length of stay, level of care, inpatient readmissions, and billing and claims processing. The role resolves escalated utilization management and LTSS complaints, identifies quality-of-care concerns, supports complex claim reviews, and represents Molina in certain administrative and judicial hearings. The nurse provides clinical resources and training to peers and refers members with special needs to appropriate Molina programs.

Requirements

At least 2 years of clinical nursing experience, including at least 1 year in utilization review, medical claims review, LTSS, claims auditing, medical necessity review, and/or coding, or an equivalent combination of relevant education and experience.
Registered Nurse (RN) with an active, unrestricted license in the state of practice; a compact license is acceptable where states allow. The role requires licensure in Illinois.
Experience demonstrating knowledge of ICD-10, Current Procedural Terminology (CPT) coding, and Healthcare Common Procedure Coding (HCPC).
Experience working with applicable state, federal, and third-party regulations.
Analytical, 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.
Proficiency with Microsoft Office suite and applicable software programs.

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 healthcare certification.
Nursing experience in critical care, emergency medicine, medical/surgical, or pediatrics.
Billing and coding experience.

Responsibilities

Facilitate prospective, retrospective, and concurrent medical reviews of appeals for denied prior authorizations, including standard and expedited inpatient, outpatient, and pharmaceutical authorization appeals.
Conduct clinical and medical reviews of retrospective claims and denied cases that have been appealed or may be appealed, assessing medical necessity and appropriate billing and claims processing.
Reevaluate claims and medical records using clinical knowledge, applicable state and federal requirements, Molina policies and procedures, and professional judgment to assess services, length of stay, level of care, and inpatient readmissions.
Validate member medical records, submitted claims, and coding to support appropriate provider reimbursement.
Resolve escalated complaints related to utilization management and long-term services and supports (LTSS).
Identify and report quality-of-care issues.
Assist with complex claim reviews, including DRG validation, itemized bill review, level-of-care review, inpatient readmissions, and opportunities identified by the payment integrity analytical team; make decisions and recommendations relevant to clinical experience.
Prepare and present cases representing Molina, alongside the chief medical officer, for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings.
Review medically appropriate clinical guidelines and criteria with medical directors on denial decisions.
Provide criteria supporting recommendations to deny or modify payment decisions.
Serve as a clinical resource for utilization management, CMOs, physicians, and member or provider inquiries and appeals.
Provide training and support to clinical peers.
Identify members with special needs and refer them to appropriate Molina programs according to applicable policies and protocols.