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    Medical Claim Review Nurse (Rn)

    Molina Healthcare
    3+ years
    $23.76 - $51.49 / HOURLY
    Remote
    10 Aug. 26, 2024
    Job Description
    Job Type: Full Time Education: B.Pharm/ M.Pharm/ B.Sc/ M.Sc/Any Life Sciences Skills: Causality Assessment, Clinical SAS Programming, Communication Skills, CPC Certified, GCP guidelines, ICD-10 CM Codes, CPT-Codes, HCPCS Codes, ICD-10 CM, CPT, HCPCS Coding, ICH guidelines, ICSR Case Processing, Interpersonal Skill, Labelling Assessment, MedDRA Coding, Medical Billing, Medical Coding, Medical Terminology, Narrative Writing, Research & Development, Technical Skill, Triage of ICSRs, WHO DD Coding

    Job Description

    Job Summary

    As a clinical expert, you will review medical documentation to ensure that services meet medical necessity and the appropriate level of care, adhering to MCG/InterQual, state and federal guidelines, billing and coding regulations, and Molina policies. You will validate medical records and claims to support accurate coding, ensuring proper reimbursement for providers.

    Job Duties

    • Conduct clinical reviews of retrospective medical claims, including those that have been previously denied and are under appeal, to verify medical necessity and accurate billing.
    • Identify and report quality of care issues.
    • Assist with complex claim reviews, including DRG validation, itemized bill review, level of care assessments, inpatient readmission reviews, and other opportunities identified by the Payment Integrity team, requiring clinical decision-making.
    • Document clinical review summaries, audit findings, and audit details in the database.
    • Provide supporting documentation for denial and modification of payment decisions.
    • Re-evaluate medical claims and records independently, applying advanced clinical knowledge, federal and state regulatory requirements, Molina policies, and personal judgment to assess service appropriateness, length of stay, and level of care.
    • Review clinical guidelines and criteria with Medical Directors on denial decisions.
    • Supply supporting criteria for all denial or payment modification recommendations.
    • Serve as a clinical resource for Utilization Management, Chief Medical Officers, Physicians, and Member/Provider Inquiries/Appeals.
    • Provide training and support to clinical peers.
    • Identify and refer members with special needs to appropriate Molina Healthcare programs as per policy and protocol.

    Job Qualifications

    • Graduation from an accredited School of Nursing.

    Required Experience, Knowledge, Skills & Abilities

    • Minimum of 3 years of clinical nursing experience.
    • At least 1 year of experience in Utilization Review and/or Medical Claims Review.
    • A minimum of 2 years of experience in Claims Auditing, Medical Necessity Review, and Coding.
    • Familiarity with state and federal regulations.

    Required License, Certification, Association

    • Active, unrestricted State Registered Nursing (RN) license in good standing.

    Preferred Education

    • Bachelor’s Degree in Nursing or a related health field.

    Preferred Experience

    • Nursing experience in Critical Care, Emergency Medicine, Medical-Surgical, or Pediatrics.
    • Advanced Practice Nursing.
    • Billing and coding experience.

    Preferred License, Certification, Association

    • Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional in Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other relevant healthcare certifications.

    Application Process for Current Molina Employees

    If you are a current Molina employee interested in applying for this position, please apply through the intranet job listing.

    About Molina Healthcare

    Molina Healthcare is a Fortune 500 company committed to providing quality healthcare to individuals receiving government assistance. We offer a competitive benefits and compensation package and foster a team-oriented environment. If you are passionate about making a difference and seeking a meaningful opportunity, join our dedicated workforce and contribute to our mission. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

    Pay Range

    $23.76 - $51.49 per hour. Actual compensation may vary based on geographic location, work experience, education, and skill level.

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