Utilization Review Nurse: Medical Claims & Coding Expert

Molina Healthcare; Phoenix (AZ); On-site; USD 83,240,000 - 162,296,000; Full time

Job summary

Molina Healthcare seeks a Registered Nurse for utilization review to evaluate medical necessity and appropriate level of care using MCG/InterQual, CPT/HCPCS coding, and Molina policies. You will validate medical records and claims to ensure proper reimbursement for providers.

The role covers prospective, retrospective, and concurrent reviews, with responsibilities in appeals, DRG validation, and collaboration with CMOs. Strong analytical and communication skills are essential.

Qualifications

• Active RN license in state of practice (unrestricted).
• 2+ years clinical nursing experience including utilization review, medical claims review, LTSS, or related.
• Experience with ICD-10, CPT, HCPCS coding.

Responsibilities

• Review documentation to assess medical necessity and level of care.
• Facilitate medical reviews for prior authorizations and appeals.
• Assess claims and records to ensure appropriate reimbursement.
• Apply state/federal regulations and Molina policies.
• Identify and report quality of care issues.
• Prepare cases for administrative hearings and reviews.

Skills

Analytical skills

Problem-solving

Decision-making

Organizational skills

Time-management

Attention to detail

Critical-thinking

Active listening

Verbal communication

Written communication

Microsoft Office

Education

RN license

Compact license acceptable

Tools

Microsoft Office

Job description

Molina Healthcare seeks a Registered Nurse for utilization review to evaluate medical necessity and appropriate level of care using MCG/InterQual, CPT/HCPCS coding, and Molina policies. You will validate medical records and claims to ensure proper reimbursement for providers.

The role covers prospective, retrospective, and concurrent reviews, with responsibilities in appeals, DRG validation, and collaboration with CMOs. Strong analytical and communication skills are essential.