RN - Clinical Utilization & Medical Appeals

Molina Healthcare; San Antonio (TX); On-site; USD 63,000 - 124,000; Full time

Job summary

Molina Healthcare in San Antonio, TX is seeking a Nurse RN for Utilization Review and medical claims review to ensure compliance with state and federal requirements and Molina policies. You will support clinical reviews, determine medical necessity, and assist with complex claim reviews.

The role requires strong coding knowledge (ICD-10, CPT, HCPCS), analytic skills, and effective communication. This on-site position offers collaborative guidance from leaders and opportunities to impact care

Qualifications

• Active RN license in state of practice.
• 2+ years nursing experience including utilization review/LTSS/coding or equivalent.
• Knowledge of ICD-10, CPT, HCPCS for medical claims.
• Experience with state, federal and third-party regulations.
• Strong analytic, problem-solving and decision-making skills.
• Excellent organizational and time-management abilities.
• Effective verbal and written communication skills.

Responsibilities

• Facilitates clinical reviews of retroactive claims and denials to ensure medical necessity and proper billing.
• Reevaluates claims with clinical judgement per regulatory guidelines and Molina policies.
• Validates claims, coding, and reimbursement accuracy.
• Resolves escalated utilization management and LTSS issues.
• Identifies and reports quality of care concerns.
• Presents cases with CMO for administrative hearings as needed.
• Supports denial/modification decisions with supporting criteria.
• Serves as clinical resource for inquiries and appeals.
• Provides training to clinical peers.

Skills

RN nursing

ICD-10 knowledge

CPT/HCPCS coding

Analytical thinking

Problem solving

Attention to detail

Verbal & written communication

Microsoft Office

Tools

Microsoft Office

Healthcare software

Job description

Molina Healthcare in San Antonio, TX is seeking a Nurse RN for Utilization Review and medical claims review to ensure compliance with state and federal requirements and Molina policies. You will support clinical reviews, determine medical necessity, and assist with complex claim reviews.

The role requires strong coding knowledge (ICD-10, CPT, HCPCS), analytic skills, and effective communication. This on-site position offers collaborative guidance from leaders and opportunities to impact care