RN Medical Review & Coding Specialist

Molina Talent Acquisition; United States; Vor Ort; USD 85.000 - 115.000; Vollzeit

Benefits dieser Stelle

Competitive benefits package

Equal Opportunity Employer

Zusammenfassung

Molina Healthcare is seeking a Registered Nurse with experience in utilization review to review documentation for medical necessity and appropriate level of care, ensuring compliant coding and proper reimbursement to providers.

You will lead medical reviews of appeals, validate records against guidelines, and collaborate with CMOs and physicians to resolve complex cases. A strong emphasis on documentation, communication, and quality improvement is required.

Qualifikationen

• RN license active and unrestricted in state of practice.
• 2+ years clinical nursing experience including 1+ year in utilization review/coding/claims
• Experience with ICD-10, CPT, HCPCS coding and related regulations

Aufgaben

• Review medical necessity and level of care using guidelines (MCG/InterQual, state/federal) and Molina policies.
• Facilitate medical review of prospective, retrospective and concurrent reviews for appeals of prior authorizations.
• Assess services via clinical judgment to determine appropriateness of length of stay and inpatient readmission risk.
• Validate member records and coding to ensure accurate reimbursement to providers.
• Resolve escalated complaints related to utilization management and LTSS.
• Identify and report quality of care issues and opportunities for improvement.
• Prepare and present cases for administrative hearings when required.
• Consult with medical directors on denial decisions and applicable criteria.
• Provide training and support to clinical peers and staff.

Kenntnisse

Analytical thinking

Problem-solving

Decision-making

Time-management

Attention to detail

Critical-thinking

Communication

MS Office proficiency

Ausbildung

RN license

Tools

Microsoft Office

Jobbeschreibung

Molina Healthcare is seeking a Registered Nurse with experience in utilization review to review documentation for medical necessity and appropriate level of care, ensuring compliant coding and proper reimbursement to providers.

You will lead medical reviews of appeals, validate records against guidelines, and collaborate with CMOs and physicians to resolve complex cases. A strong emphasis on documentation, communication, and quality improvement is required.