Medical Review Nurse Jobs

About The Position

Requirements

• At least 2 years of clinical nursing experience, including at least 1 year in utilization review (prospective, retrospective, or concurrent clinical review), medical claims review, LTSS, claims auditing, medical necessity review, and/or coding; an equivalent combination of relevant education and experience is acceptable.
• Active, unrestricted Registered Nurse (RN) license in the state of practice (Idaho or Utah); a 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

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

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, appealed claims, and cases likely to be appealed to assess medical necessity, billing accuracy, and claims processing.
• Reevaluate medical claims and records using clinical expertise, applicable state and federal requirements, Molina policies and procedures, and professional judgment.
• Assess appropriateness of services, length of stay, level of care, and inpatient readmissions.
• Validate member medical records and submitted claims for correct coding and 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 readmissions, and opportunities identified by the payment integrity analytical team; make decisions and recommendations relevant to clinical experience.
• Prepare and present cases representing Molina, with the CMO, for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings.
• Review medically appropriate clinical guidelines and other relevant 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 and 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.

Benefits

• Competitive benefits and compensation package.