RN Utilization Review & Appeals Specialist

Jobtome; Illinois City (IL); On-site; USD 42,000 - 82,000; Full time

Job summary

Jobtome is seeking an experienced Registered Nurse to lead utilization review activities, reviewing medical records and claims for medical necessity and appropriate coding to secure proper reimbursement.

The role includes handling prospective, retrospective, and concurrent reviews, presenting cases with the CMO, and advising on complex claims while ensuring compliance with state and federal regulations and Molina policies.

Qualifications

• Active RN license in state of practice; compact license acceptable where permitted.
• At least 2 years clinical nursing experience with utilization review and/or coding experience.
• Experience with ICD-10, CPT coding and HCPC.
• Experience with state, federal, and third-party regulations.
• Strong analytical, problem-solving and decision-making skills.
• Excellent organizational and time-management abilities.
• Attention to detail; strong verbal and written communication.
• Proficiency in Microsoft Office and relevant software.

Responsibilities

• Facilitate medical reviews for prospective, retrospective, and concurrent reviews of appeals for denied prior authorizations.
• Facilitate clinical reviews of retrospective reviews of medical claims and previously denied cases.
• Reevaluate medical claims by applying regulatory requirements and Molina policies.
• Validate member records and claims to ensure proper reimbursement to providers.
• Resolve escalated complaints regarding utilization management and LTSS issues.
• Identify and report quality of care issues.
• Assist with complex claim reviews including DRG validation and LTSS opportunities.
• Prepare and present cases for administrative hearings with the CMO.
• Review guidelines and criteria with medical directors on denial decisions.
• Provide training and support to clinical peers.
• Refer members with special needs to Molina programs.

Skills

Analytic and problem-solving

Time management

Attention to detail

Critical thinking

Verbal and written communication

Education

RN license

Tools

Microsoft Office

Job description

Jobtome is seeking an experienced Registered Nurse to lead utilization review activities, reviewing medical records and claims for medical necessity and appropriate coding to secure proper reimbursement.

The role includes handling prospective, retrospective, and concurrent reviews, presenting cases with the CMO, and advising on complex claims while ensuring compliance with state and federal regulations and Molina policies.