Medical Claim Review Nurse (RN) Remote IL & WI

Molina Healthcare; Long Beach (CA); Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a dedicated Registered Nurse to join their Appeals and Grievances department. This remote position requires clinical expertise to review medical claims and ensure compliance with regulations while utilizing advanced clinical judgment. The ideal candidate will have a strong background in nursing, claims auditing, and medical necessity review, along with excellent organizational and problem-solving skills. This role offers the opportunity to make a significant impact in the healthcare sector, supporting quality care and appropriate reimbursement processes. If you're passionate about improving patient outcomes and have the required experience, this could be the perfect opportunity for you.

Benefits

Competitive benefits package

Equal Opportunity Employer

Work from home flexibility

Qualifications

• 3+ years clinical nursing experience required.
• Experience in Utilization Review and Medical Claims Review is essential.
• Familiarity with state and federal regulations is a must.

Responsibilities

• Perform clinical reviews of medical claims to ensure accuracy.
• Document findings and provide support for payment decisions.
• Serve as a clinical resource for various stakeholders.

Skills

Clinical Judgment

Organization Skills

Multitasking

Problem Solving

Claims Auditing

Medical Necessity Review

Knowledge of State/Federal Regulations

Education

Bachelor's Degree in Nursing

Graduate from an Accredited School of Nursing

Tools

MS Office

PEGA

QNXT

MCG

Job description

JOB DESCRIPTION

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.

This position will be supporting our Appeals and Grievances department. We are seeking a Registered Nurse with previous claims and appeals experience. The candidate must have strong skills with organization, multitasking, problem solving, and using clinical judgment. Candidates with proficient knowledge of MS Office, PEGA, QNXT, MCG is highly preferred. Further details to be discussed during our interview process.

This is a remote position.

Illinois & Wisconsin RN compact licensure required

Work hours: Monday- Friday: 8:30am -5:00pm. Central Time. Along with every 8 weeks Friday coverage is from 9 to 5:30pm CST for 2 weeks.

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

REQUIREDEXPERIENCE/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

REQUIREDLICENSE,CERTIFICATION,ASSOCIATION:

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

PREFERREDEDUCATION:

Bachelors’s Degree in Nursing or Health Related Field

PREFERREDEXPERIENCE:

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

PREFERREDLICENSE,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.