Utilization Review RN - Medical Claims & Coding Expert

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

Job summary

Molina Healthcare is seeking an experienced utilization review nurse in Arizona to review documentation for medical necessity and appropriate level of care. The role involves applying MCG/InterQual guidelines, billing rules, and Molina policies to validate records and support correct reimbursement.

The position requires 2+ years of clinical nursing experience with UR, active RN license, ICD-10/CPT/HCPCS knowledge, and strong analytical skills.

Qualifications

• Minimum 2 years of clinical nursing experience including utilization review or related coding/claims duties.
• Active RN license in state of practice; compact license acceptable where allowed.
• Experience with ICD-10, CPT coding, HCPCS, and related billing rules.
• Experience navigating state, federal, and third‑party regulations.
• Strong analytical, problem-solving and decision-making skills.
• Excellent organizational and time-management abilities.
• Attention to detail and strong written/verbal communication.
• Proficiency with standard software programs.

Responsibilities

• Facilitate medical reviews for prospective, retrospective and concurrent reviews of appeals.
• Review retrospective medical claims and denied cases to ensure medical necessity and proper billing.
• Reevaluate claims using clinical knowledge and regulatory guidelines to assess care level and length of stay.
• Validate member records and claims to ensure correct coding and reimbursement.
• Resolve escalated utilization management and LTSS-related complaints.
• Present cases to leadership for administrative hearings and regulatory hearings as needed.
• Provide training and support to clinical peers and serve as a resource for inquiries/appeals.
• Identify members with special needs and refer to Molina programs per policy.

Skills

Utilization review experience

RN

ICD-10 CPT HCPCS knowledge

Analytic decision making

Attention to detail

Verbal and written communication

Microsoft Office proficiency

Education

Registered Nurse (RN) License

Tools

Microsoft Office

Job description

Molina Healthcare is seeking an experienced utilization review nurse in Arizona to review documentation for medical necessity and appropriate level of care. The role involves applying MCG/InterQual guidelines, billing rules, and Molina policies to validate records and support correct reimbursement.

The position requires 2+ years of clinical nursing experience with UR, active RN license, ICD-10/CPT/HCPCS knowledge, and strong analytical skills.