Medical Claim Review Nurse (RN)

Molina Healthcare; Salt Lake City (UT); Remote; USD 80,000 - 100,000; Full time

Job summary

A leading healthcare company is seeking a remote RN with expertise in appeals, claims review, and medical coding. The candidate will utilize their clinical knowledge to review documentation ensuring medical necessity and compliance with regulations while working Monday to Friday. The ideal candidate should have at least 3 years of clinical nursing experience and an active RN license.

Benefits

Competitive benefits package

Equal Opportunity Employer

Qualifications

• Graduate from an Accredited School of Nursing.
• Minimum 3 years clinical nursing experience.
• Active, unrestricted State Registered Nursing (RN) license in good standing.

Responsibilities

• Perform clinical medical reviews of retrospective medical claim reviews.
• Identify and report quality of care issues.
• Document clinical review summaries and audit findings.

Skills

Clinical Nursing Experience

Utilization Review

Medical Claims Review

Claims Auditing

Education

Bachelor's Degree in Nursing or Health Related Field

Tools

MCG/InterQual

Clinical Guidelines

Job description

JOB DESCRIPTION

Looking for a RN that has a current active unrestricted license

This a remote role and can sit anywhere within the United States.

Work Schedule Monday to Friday - operation hours 6 AM to 6 PM (Team will work on set schedule)

Looking for a RN with experience with appeals, claims review, and medical coding.

Job Summary

Utilizing clinical knowledge and experience, responsible for review of documentation to ensure medical necessity and appropriate level of care utilizing MCG/InterQual, state/federal guidelines, billing and coding regulations, and Molina policies; validates the medical record and claim submitted support correct coding to ensure appropriate reimbursement to providers.

Job Duties

• Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing.

• Identifies and reports quality of care issues.

• Assists with Complex Claim review including DRG Validation, Itemized Bill Review, Appropriate Level of Care, Inpatient Readmission, and any opportunity identified by the Payment Integrity analytical team; requires decision making pertinent to clinical experience

• Documents clinical review summaries, bill audit findings and audit details in the database

• Provides supporting documentation for denial and modification of payment decisions

• Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care.

• Reviews medically appropriate clinical guidelines and other appropriate criteria with Medical Directors on denial decisions.

• Supplies criteria supporting all recommendations for denial or modification of payment decisions.

• Serves as a clinical resource for Utilization Management, Chief Medical Officers, Physicians, and Member/Provider Inquiries/Appeals.

• Provides training and support to clinical peers.

• Identifies and refers members with special needs to the appropriate Molina Healthcare program per policy/protocol.

JOB QUALIFICATIONS

Graduate from an Accredited School of Nursing

REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:

• Minimum 3 years clinical nursing experience.

• Minimum one year Utilization Review and/or Medical Claims Review.

• Minimum two years of experience in Claims Auditing, Medical Necessity Review and Coding experience

• Familiar with state/federal regulations

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

Active, unrestricted State Registered Nursing (RN) license in good standing.

PREFERRED EDUCATION:

Bachelors’s Degree in Nursing or Health Related Field

PREFERRED EXPERIENCE:

Nursing experience in Critical Care, Emergency Medicine, Medical Surgical, or Pediatrics. Advanced Practice Nursing. Billing and coding experience.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Certified Clinical Coder, Certified Medical Audit Specialists, Certified Case Manager , Certified Professional Healthcare Management, Certified Professional in Healthcare Quality or other healthcare certification.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $26.41 - $61.79 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.