RN Medical Review & Utilization Specialist

Molina Healthcare, Inc.; United States; On-site; USD 90,000 - 120,000; Full time

Job summary

Molina Healthcare, Inc. is seeking a skilled nursing professional to join its Utilization Management team.

The role focuses on clinical review of documentation to verify medical necessity, appropriate level of care, and compliant coding under state/federal guidelines and Molina policies. The position involves reviewing prospective, retrospective, and concurrent cases, supporting denials and appeals, and collaborating with medical directors to ensure accurate reimbursement and quality of care

Qualifications

• Minimum 2 years of clinical nursing experience including 1 year in utilization review.
• RN with active license (ID or UT; compact where applicable).
• Experience with ICD-10, CPT, and HCPCS coding.
• Experience with state, federal, and third-party regulations.
• Strong analytic, problem-solving and decision-making skills.
• Strong organizational and time-management skills.
• Attention to detail and critical-thinking and active listening.
• Proficiency in Microsoft Office and related software.
• Effective verbal and written communication.

Responsibilities

• Facilitates medical review of prospective, retrospective, and concurrent review of appeals for denied prior authorizations.
• Facilitates clinical/medical reviews of retrospective medical claim reviews and denied cases to ensure medical necessity and accurate billing.
• Reevaluates medical claims by applying clinical knowledge and applicable regulations to assess services, length of stay, and level of care.
• Validates member medical records and claims to ensure proper reimbursement.
• Resolves escalated complaints regarding utilization management and LTSS issues.
• Identifies and reports quality of care issues.
• Assists with complex claim review including DRG validation and inpatient readmission decisions.
• Prepares and presents cases for administrative hearings with senior leadership.
• Reviews guidelines and criteria with medical directors on denial decisions.
• Supplies criteria supporting all denial or modification recommendations.
• Serves as a clinical resource for utilization management and inquiries.

Skills

Utilization review

Medical claims review

LTSS knowledge

Claims auditing

Medical necessity review

Coding experience

RN license

ICD-10 knowledge

CPT coding

HCPCS knowledge

Regulatory knowledge

Analytic thinking

Time management

Communication skills

Microsoft Office

Education

Registered Nurse license

Tools

Microsoft Office

Job description

Molina Healthcare, Inc. is seeking a skilled nursing professional to join its Utilization Management team.

The role focuses on clinical review of documentation to verify medical necessity, appropriate level of care, and compliant coding under state/federal guidelines and Molina policies. The position involves reviewing prospective, retrospective, and concurrent cases, supporting denials and appeals, and collaborating with medical directors to ensure accurate reimbursement and quality of care