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 documentation for medical necessity and appropriate level of care, applying MCG/InterQual criteria, state and federal guidelines, billing and coding regulations, and Molina policies. The role validates medical records and claims to support correct coding and appropriate provider reimbursement. The nurse conducts reviews of prior authorization appeals and retrospective medical claims, including standard and expedited cases across inpatient, outpatient, and pharmaceutical services. The position evaluates services provided, length of stay, level of care, and inpatient readmissions; supports complex claim reviews; resolves escalated utilization management and LTSS complaints; and identifies quality-of-care issues. The role also prepares and presents cases with Molina’s chief medical officer at administrative and judicial hearings, consults with medical directors on clinical guidelines and denial decisions, supports clinical colleagues and stakeholders as a clinical resource, provides peer training, 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) license that is active and unrestricted in the state of practice; a compact license is acceptable where states allow.
Experience demonstrating knowledge of ICD-10, CPT coding, and HCPC.
Experience working with 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.
Proficiency with Microsoft Office 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 review of appeals for denied prior authorizations, including standard and expedited inpatient, outpatient, and pharmaceutical authorization appeals.
Conduct clinical and medical reviews of retrospective medical claims, appealed or potentially appealed claims, and previously denied cases to assess medical necessity and accurate billing and claims processing.
Reevaluate claims and associated records using clinical knowledge, applicable regulations and guidelines, Molina policies and procedures, and professional judgment to assess services, length of stay, level of care, and inpatient readmissions.
Validate member medical records, claims, and coding to support appropriate provider reimbursement.
Resolve escalated complaints involving 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 readmission review, and opportunities identified by the payment integrity analytical team.
Prepare and present cases representing Molina, together with the chief medical officer, for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings.
Review medically appropriate clinical guidelines and other criteria with medical directors regarding 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 and refer members with special needs to the appropriate Molina program according to applicable policies and protocols.