Medical Review Nurse (RN)

Molina Healthcare•United States,

12h•$26 - $57

About The Position

The Medical Review Nurse uses clinical knowledge and experience to review documentation for medical necessity, appropriate level of care, accurate coding, and appropriate provider reimbursement. The role applies MCG/InterQual criteria, state and federal guidelines, billing and coding regulations, and Molina policies. As part of the Clinical Advanced Imaging Team, the nurse reviews specialized advanced imaging cases, including MRIs and CT scans, and supports operations across all states for Medicaid and Marketplace lines of business.

Requirements

At least 2 years of clinical nursing experience, including at least 1 year in utilization review (prospective, retrospective, and concurrent clinical 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; compact license is acceptable where permitted.
Experience demonstrating knowledge of ICD-10, CPT coding, and 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 another healthcare certification.
Nursing experience in critical care, emergency medicine, medical/surgical, or pediatrics.
Billing and coding experience.

Responsibilities

Conduct prospective, retrospective, and concurrent medical reviews of appeals for denied prior authorizations, including standard and expedited cases and inpatient, outpatient, and pharmaceutical authorization appeals.
Review retrospective medical claims, appealed or potentially appealed denied cases, and associated records for medical necessity, appropriate billing, and accurate 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, claims, and coding to support appropriate provider reimbursement.
Resolve escalated complaints involving utilization management and long-term services and supports issues.
Identify and report quality-of-care issues.
Assist with complex claim reviews, including DRG validation, itemized bill review, level-of-care assessment, inpatient readmission review, and opportunities identified by the payment integrity analytical team; make decisions and recommendations based on clinical experience.
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 members with special needs and refer them to the appropriate Molina program according to applicable policies and protocols.