Clinical Review Nurse: Utilization & Coding Expert

Molina Healthcare; Tucson (AZ); On-site; USD 40,000 - 79,000; Full time

Job summary

Molina Healthcare is seeking a utilization review RN to review documentation for medical necessity and appropriate level of care, ensuring accurate coding and reimbursement. The role involves appeals review, claims analysis, and collaboration with CMOs and medical directors.

Responsibilities include validating records, resolving LTSS issues, and supporting clinical peers with training. Requires active RN license, knowledge of ICD-10, CPT/HCPC, and strong analytical skills.

Qualifications

• At least 2 years clinical nursing experience, incl. 1 year of utilization review or coding.
• RN license active and unrestricted; compact license acceptable where allowed.
• Experience with ICD-10, CPT, HCPC coding.
• Knowledge of applicable state, federal, and third-party regulations.
• Strong analytical, organizational, and communication skills.

Responsibilities

• Facilitates medical review of prospective, retrospective, and concurrent review of appeals for denied prior authorizations.
• Facilitates clinical/medical reviews of retrospective medical claim reviews and denied cases to ensure medical necessity and accurate billing.
• Reevaluates medical claims applying clinical knowledge and regulatory guidelines for appropriateness of services, length of stay, and inpatient readmissions.
• Validates member records and claims to ensure proper reimbursement to providers.
• Resolves escalated complaints regarding utilization management and LTSS issues.
• Identifies and reports quality of care issues.
• Assists with complex claim review including DRG validation and inpatient readmission analysis.
• Prepares and presents cases for administrative hearings as needed.
• Reviews guidelines with medical directors on denial decisions.
• Provides training and support to clinical peers.
• Identifies and refers members to Molina programs per policy.

Skills

Analytic thinking

Decision making

Time management

Attention to detail

Verbal & written communication

Microsoft Office

Coding knowledge (ICD-10 CPT HCPC)

Education

RN license (active)

Job description

Molina Healthcare is seeking a utilization review RN to review documentation for medical necessity and appropriate level of care, ensuring accurate coding and reimbursement. The role involves appeals review, claims analysis, and collaboration with CMOs and medical directors.

Responsibilities include validating records, resolving LTSS issues, and supporting clinical peers with training. Requires active RN license, knowledge of ICD-10, CPT/HCPC, and strong analytical skills.