Medical Review Nurse (RN)

Molina Healthcare•United States,

6d•$26 - $57

About The Position

Using clinical knowledge and experience, the Medical Review Nurse reviews documentation to ensure medical necessity and the 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 prospective, retrospective, and concurrent medical reviews, including appeals of denied prior authorizations and retrospective medical claims. Reviews cover standard and expedited cases, inpatient, outpatient, and pharmaceutical authorization appeals. The role also assesses services provided, length of stay, level of care, inpatient readmissions, billing accuracy, and claims processing. Additional duties include resolving escalated utilization management and LTSS complaints, identifying quality-of-care issues, assisting with complex claims and DRG validation, and representing Molina in administrative and judicial hearings. The nurse works with medical directors on denial decisions, supplies criteria for recommendations, serves as a clinical resource, trains and supports 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.
Active, unrestricted Registered Nurse (RN) license in the state of practice (Idaho or Utah); a compact license is acceptable where states allow.
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 and applicable software programs.

Nice To Haves

Nursing experience in critical care, emergency medicine, medical/surgical, or pediatrics.
Billing and coding experience.
Utah, Idaho, or compact nursing license.

Responsibilities

Conduct prospective, retrospective, and concurrent medical reviews of appeals for denied prior authorizations, including standard and expedited inpatient, outpatient, and pharmaceutical authorization appeals.
Review retrospective medical claims and previously denied cases that have been appealed or may be appealed to assess medical necessity, billing accuracy, and claims processing.
Reevaluate claims and medical records using clinical knowledge, applicable state and federal requirements, Molina policies, 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 concerning 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 assessment, inpatient readmissions, 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 clinically appropriate 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/provider inquiries and appeals.
Provide training and support to clinical peers.
Identify and refer members with special needs to the appropriate Molina program under applicable policies and protocols.