Utilization Review Nurse: Medical Necessity & Claims Expert

Molina Healthcare; Arizona; On-site; USD 40,000 - 78,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare is seeking an RN Utilization Review Nurse in the United States to review documentation for medical necessity and appropriate level of care, applying MCG/InterQual guidelines and billing standards.

Responsibilities include reviewing prospective, retrospective, and concurrent cases, validating records for correct coding, and supporting reimbursement while ensuring compliance with state and federal regulations. Collaborative role with CMOs and providers.

Qualifications

• Requires RN license, active and unrestricted.
• 2+ years clinical nursing with utilization review or coding experience.
• Experience with ICD-10, CPT, HCPCS coding.
• Knowledge of state and federal regulations.

Responsibilities

• Review medical records to confirm medical necessity and appropriate level of care.
• Facilitate prospective, retrospective, and concurrent reviews for denials and appeals.
• Assess claims and documentation for accurate coding and reimbursement.
• Ensure compliance with ICD-10, CPT, HCPCS and regulatory guidelines.
• Provide input on complex claim reviews and DRG validation.
• Serve as clinical resource for utilization management and providers.
• Train clinical peers and support LTSS-related processes.

Skills

Analytical thinking

Problem-solving

Attention to detail

Verbal communication

Written communication

Education

Registered Nurse (RN) license active in state

Compact license acceptable where available

Tools

Microsoft Office

Job description

Molina Healthcare is seeking an RN Utilization Review Nurse in the United States to review documentation for medical necessity and appropriate level of care, applying MCG/InterQual guidelines and billing standards.

Responsibilities include reviewing prospective, retrospective, and concurrent cases, validating records for correct coding, and supporting reimbursement while ensuring compliance with state and federal regulations. Collaborative role with CMOs and providers.