Utilization Review Nurse: Medical Claims & Care Validation

Molina Healthcare; Glendale (AZ); On-site; USD 40,000 - 79,000; Full time

Job summary

Molina Healthcare is seeking a Nurse Reviewer to support utilization management in Arizona. You will review documentation to confirm medical necessity and appropriate care level using MCG/InterQual guidelines and Molina policies, validating records to ensure accurate reimbursement for providers.

Responsibilities include prospective/retrospective/concurrent reviews for denials, DRG validation, and appeals support.

Qualifications

• Active RN license in state of practice (compact license acceptable where allowed).
• 2+ years clinical nursing, including 1 year in utilization review or related areas.
• Experience with ICD-10, CPT, HCPCS coding and medical billing regulations.

Responsibilities

• Facilitate medical reviews of prospective, retrospective, and concurrent reviews for denials.
• Review retrospective medical claims and denied cases to ensure medical necessity.
• Apply clinical knowledge to assess level of care, length of stay, and inpatient readmissions.
• Validate member records and ensure correct coding for reimbursement.
• Resolve escalated LTSS and utilization management complaints.
• Prepare and present cases for administrative hearings with Molina leadership.
• Collaborate with medical directors and CMOs on denial decisions.
• Provide training and support to clinical peers.

Skills

Analytical skills

Problem solving

Decision making

Organizational skills

Time management

Attention to detail

Communication skills

Verbal and written communication

Common look proficiency

Education

Registered Nurse (RN) license

Tools

Microsoft Office suite

Job description

Molina Healthcare is seeking a Nurse Reviewer to support utilization management in Arizona. You will review documentation to confirm medical necessity and appropriate care level using MCG/InterQual guidelines and Molina policies, validating records to ensure accurate reimbursement for providers.

Responsibilities include prospective/retrospective/concurrent reviews for denials, DRG validation, and appeals support.