Utilization Review Nurse: Medical Necessity & Claims Expert

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

Job summary

Molina Healthcare seeks a Nurse Reviewer to conduct medical necessity reviews and ensure accurate coding for reimbursement. You will perform prospective, retrospective, and concurrent reviews, including appeals, DRG validation, and LTSS considerations, applying ICD-10, CPT/HCPCS, and state/federal guidelines.

Collaborate with medical directors and the CMO, present cases for hearings, train clinical peers, and identify members for Molina programs per policy.

Qualifications

• At least 2 years clinical nursing experience with 1 year in utilization review, claims review, LTSS, or coding.
• Active RN license in state of practice; compact license acceptable where allowed.
• Experience with ICD-10, CPT, and HCPCS coding.
• Experience with applicable state, federal, and third-party regulations.
• Analytic, problem-solving, and decision-making skills.
• Organizational and time-management skills.
• Attention to detail.
• Critical-thinking and active listening skills.
• Proficiency in Microsoft Office and related software.

Responsibilities

• Facilitates medical review of appeals for denied prior authorizations across cases.
• Reviews retrospective medical claims and denied cases for medical necessity and accurate billing.
• Reevaluates claims using clinical knowledge to assess level of care and length of stay.
• Validates member records and claims for correct coding and reimbursement.
• Resolves escalated complaints regarding utilization management and LTSS.
• Identifies and reports quality of care issues.
• Assists with complex claim reviews including DRG validation and readmission assessments.
• Prepares and presents cases for administrative hearings with the CMO.
• Reviews guidelines with medical directors on denial decisions.
• Provides training and support to clinical peers.
• Identifies members with special needs and refers to Molina programs.

Skills

Analytic 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

Tools

Microsoft Office

Job description

Molina Healthcare seeks a Nurse Reviewer to conduct medical necessity reviews and ensure accurate coding for reimbursement. You will perform prospective, retrospective, and concurrent reviews, including appeals, DRG validation, and LTSS considerations, applying ICD-10, CPT/HCPCS, and state/federal guidelines.

Collaborate with medical directors and the CMO, present cases for hearings, train clinical peers, and identify members for Molina programs per policy.