Remote RN: Medical Review & Utilization Specialist

Molina Healthcare; Illinois; Remote; USD 41,000 - 81,000; Full time

Job summary

Molina Healthcare is seeking a Medical Review Nurse (RN) to review documentation for medical necessity and appropriate levels of care, using clinical knowledge and utilization review expertise. This remote US role offers a full-time schedule.

Responsibilities include coordinating prospective, retrospective, and concurrent reviews of prior authorizations, reevaluating claims, validating coding, and supporting denial decisions with clinical guidance.

Qualifications

• Active RN license required
• 2+ years clinical nursing experience, including 1 year in utilization review or medical claims review
• Experience with ICD-10, CPT coding, and HCPCS

Responsibilities

• Facilitate medical review of prospective, retrospective, and concurrent reviews for denied prior authorizations.
• Review retrospective medical claims and previously denied cases.
• Reevaluate medical claims and records for appropriate services.
• Validate member medical records and claims for correct coding.
• 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 itemized bill review.
• Prepare and present cases for administrative hearings and state insurance commissions.
• Review guidelines with medical directors on denial decisions.
• Serve as a clinical resource for utilization management and member/provider inquiries.

Skills

Clinical nursing experience

Utilization review experience

Job description

Molina Healthcare is seeking a Medical Review Nurse (RN) to review documentation for medical necessity and appropriate levels of care, using clinical knowledge and utilization review expertise. This remote US role offers a full-time schedule.

Responsibilities include coordinating prospective, retrospective, and concurrent reviews of prior authorizations, reevaluating claims, validating coding, and supporting denial decisions with clinical guidance.