Remote RN: Medical Review & Coding Specialist

Molina Healthcare; United States; On-site; USD 36,000 - 78,000; Full time

Job summary

Molina Healthcare is seeking a Medical Review Nurse in the United States to evaluate documentation for medical necessity and appropriate level of care using MCG/InterQual guidelines and Molina policies; ensures proper reimbursement through correct coding and thorough review.

Two years of clinical nursing experience and at least one year in utilization review, medical claims review, or coding are required. Proficiency in MS Office and multitasking across screens are essential.

Qualifications

• 2+ years clinical nursing experience with utilization review and/or coding experience.
• RN license active and unrestricted; compact license acceptable where allowed.
• Knowledge of ICD-10, CPT coding and HCPCS.
• Experience with state, federal, and third-party regulations.
• Strong analytic, problem-solving and time-management skills.
• Excellent written and verbal communication; MS Office proficiency.

Responsibilities

• Facilitate medical review of appeals for prior authorizations (prospective, retrospective, concurrent).
• Review retrospective medical claims and ensure medical necessity and accurate billing.
• Reevaluate claims using clinical knowledge and applicable guidelines and Molina policies.
• Validate member records and correct coding to ensure reimbursement.
• Resolve escalated utilization management and LTSS issues.
• Identify and report quality of care issues.
• Prepare and present cases for administrative hearings.
• Review clinical guidelines with medical directors on denials.
• Provide clinical resources and training to peers.
• Refer members with special needs to Molina programs.

Skills

Analytical thinking

Time management

Attention to detail

Communication skills

Problem solving

Active listening

Organizational skills

MS Office proficiency

Education

RN license

Compact/multi-state license

Tools

ICD-10

CPT coding

HCPCS

Job description

Molina Healthcare is seeking a Medical Review Nurse in the United States to evaluate documentation for medical necessity and appropriate level of care using MCG/InterQual guidelines and Molina policies; ensures proper reimbursement through correct coding and thorough review.

Two years of clinical nursing experience and at least one year in utilization review, medical claims review, or coding are required. Proficiency in MS Office and multitasking across screens are essential.