Medical Review Nurse (Rn)- Post Appeals (Must Be Licensed In Illinois)

Jobtome; Illinois City (IL); On-site; USD 42,000 - 82,000; Full time

Job summary

Jobtome is seeking an experienced Registered Nurse to lead utilization review activities, reviewing medical records and claims for medical necessity and appropriate coding to secure proper reimbursement.

The role includes handling prospective, retrospective, and concurrent reviews, presenting cases with the CMO, and advising on complex claims while ensuring compliance with state and federal regulations and Molina policies.

Qualifications

• Active RN license in state of practice; compact license acceptable where permitted.
• At least 2 years clinical nursing experience with utilization review and/or coding experience.
• Experience with ICD-10, CPT coding and HCPC.
• Experience with state, federal, and third-party regulations.
• Strong analytical, problem-solving and decision-making skills.
• Excellent organizational and time-management abilities.
• Attention to detail; strong verbal and written communication.
• Proficiency in Microsoft Office and relevant software.

Responsibilities

• Facilitate medical reviews for prospective, retrospective, and concurrent reviews of appeals for denied prior authorizations.
• Facilitate clinical reviews of retrospective reviews of medical claims and previously denied cases.
• Reevaluate medical claims by applying regulatory requirements and Molina policies.
• Validate member records and claims to ensure proper reimbursement to providers.
• Resolve escalated complaints regarding utilization management and LTSS issues.
• Identify and report quality of care issues.
• Assist with complex claim reviews including DRG validation and LTSS opportunities.
• Prepare and present cases for administrative hearings with the CMO.
• Review guidelines and criteria with medical directors on denial decisions.
• Provide training and support to clinical peers.
• Refer members with special needs to Molina programs.

Skills

Analytic and problem-solving

Time management

Attention to detail

Critical thinking

Verbal and written communication

Education

RN license

Tools

Microsoft Office

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.

Job Duties

• Facilitates medical review of prospective, retrospective, and concurrent review of appeals for denied prior authorizations. Includes standard and expedited cases, inpatient, outpatient, and pharmaceutical authorization appeals.
• Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing.
• Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions.
• Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers.
• Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues.
• Identifies and reports quality of care issues.
• Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience.
• Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings.
• 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, CMOs, physicians and member/provider inquiries/appeals.
• Provides training and support to clinical peers.
• Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols.

Job Qualifications

REQUIRED QUALIFICATIONS

• At least 2 years clinical nursing experience, including at least 1 year of utilization review (prospective, retrospective and concurrent clinical review), medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience.
• Registered Nurse (RN). License must be active and unrestricted in state of practice. Compact license is acceptable where states allow.
• Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and
• Healthcare Common Procedure Coding (HCPC).
• Experience working within applicable state, federal, and third-party regulations.
• Analytic, 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.
• Microsoft Office suite and applicable software program(s) proficiency.

PREFERRED QUALIFICATIONS

• 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 other health care certifications.
• Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics.
• Billing and coding experience.

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

Pay Range: $30.5 - $59.47 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.