RN Medical Review & Appeals Specialist

Molina Healthcare, Inc.; Rock Island (IL); On-site; USD 42,000 - 82,000; Full time

Job summary

Molina Healthcare is seeking an experienced Registered Nurse to perform utilization review and medical necessity assessments. You will review documentation against state and federal guidelines, apply coding knowledge to ensure proper reimbursement, and participate in appeals across prospective, retrospective, and concurrent cases.

The role requires at least 2 years of clinical nursing experience, including utilization review, and a strong grasp of ICD-10, CPT, and HCPCS codes.

Qualifications

• Active RN license in state of practice is required; compact license acceptable where allowed.
• At least 2 years of clinical nursing experience, incl. 1 year in utilization review/claims review/LTSS or equivalent.
• Experience with ICD-10, CPT, HCPCS coding and related regulations.
• Strong analytic, problem-solving, and decision-making abilities.
• Excellent organizational/time-management skills and attention to detail.
• Excellent verbal and written communication; proficient with Microsoft Office and similar software.

Responsibilities

• Review medical records to validate medical necessity and appropriate level of care.
• Facilitate clinical reviews of prospective, retrospective, and concurrent appeals for denials.
• Reassess claims by applying clinical knowledge and regulatory guidelines for admission/length of stay/level of care.
• Ensure correct coding to support reimbursement to providers.
• Address escalated inquiries and LTSS/quality of care issues.

Skills

ICD-10 coding

CPT coding

HCPCS coding

Utilization review

Data analysis

Decision making

Communication

Education

RN license (active)

Compact license acceptable

Tools

Microsoft Office

Job description

Molina Healthcare is seeking an experienced Registered Nurse to perform utilization review and medical necessity assessments. You will review documentation against state and federal guidelines, apply coding knowledge to ensure proper reimbursement, and participate in appeals across prospective, retrospective, and concurrent cases.

The role requires at least 2 years of clinical nursing experience, including utilization review, and a strong grasp of ICD-10, CPT, and HCPCS codes.