Utilization Review Nurse: Clinical Appeals & Coding

Molina Talent Acquisition; Arizona; On-site; USD 70,000 - 90,000; Full time

Job summary

Molina Healthcare is seeking a Registered Nurse to support utilization review, clinical documentation, and coding validation to ensure medical necessity and appropriate level of care.

The role involves reviewing appeals, DRG validation, and compliance with billing regulations, while serving as a clinical resource for physicians and staff. Strong communication and analytic skills are essential.

Qualifications

• Active, unrestricted RN license in practice state.
• Minimum 2 years nursing experience with utilization review and/or coding.
• Knowledge of ICD-10, CPT, HCPCS and coding regulations.
• Experience with state, federal, and third-party regulations.
• Strong analytical, problem-solving, and time-management skills.
• Excellent verbal and written communication.
• Proficient in Microsoft Office.

Responsibilities

• Review documentation to ensure medical necessity and appropriate level of care.
• Facilitate medical reviews of appeals for denials and reviews of LTSS and complex cases.
• Apply clinical knowledge to assess services, length of stay, level of care, and readmissions.
• Validate member records and claims for correct coding and reimbursement.
• Resolve escalated complaints regarding utilization management and LTSS issues.
• Identify and report quality of care issues.
• Assist with DRG validation, itemized bill reviews, and payment integrity efforts.
• Prepare and present cases for administrative hearings when required.
• Review guidelines with medical directors on denial decisions.
• Provide training and support to clinical peers.
• Refer members to Molina programs per policy.

Skills

Nursing experience

Utilization review

Coding knowledge

ICD-10

CPT coding

HCPCS coding

Regulatory knowledge

Analytical skills

Organization & time management

Communication skills

Attention to detail

Education

Registered Nurse (RN) license

Tools

Microsoft Office proficiency

Job description

Molina Healthcare is seeking a Registered Nurse to support utilization review, clinical documentation, and coding validation to ensure medical necessity and appropriate level of care.

The role involves reviewing appeals, DRG validation, and compliance with billing regulations, while serving as a clinical resource for physicians and staff. Strong communication and analytic skills are essential.