RN Clinical Utilization & Medical Claims Review

Molina Healthcare

Illinois

On-site

USD 43,000 - 83,000

Full time

42 hours ago

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Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare is seeking an experienced RN to perform utilization review, medical necessity assessments, and coding validation to assure proper reimbursement. You will review prospective, concurrent, and retrospective cases, support LTSS and denials workflows, and participate in complex claim reviews with clinical judgment.

Excellent communication and regulatory knowledge are essential. This role emphasizes collaboration with medical directors and CMOs, training peers, and providing expert

Qualifications

At least 2 years of clinical nursing experience with 1 year in utilization review or related coding/review.
Active RN license in state of practice; compact license accepted where allowed.
Knowledge of ICD-10, CPT, and HCPC coding and regulatory requirements.

Responsibilities

Facilitates medical review of prospective, retrospective, and concurrent reviews for denials and prior authorizations.
Resolves escalated complaints regarding utilization management and LTSS issues.
Validates medical records and coding to ensure appropriate reimbursement.
Presents cases to leadership bodies for hearings and reviews.

Skills

Utilization review

Nursing

ICD-10 coding

CPT coding

HCPCS coding

Critical thinking

Communication

Billing software

EHR

Education

RN license

Tools

Billing software

Electronic Health Records (EHR)

Job description

Excellent communication and regulatory knowledge are essential. This role emphasizes collaboration with medical directors and CMOs, training peers, and providing expert

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