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2h ago Curated

Appeals Medical Review Nurse - REMOTE- PST Schedule

Molina Healthcare

Job description

Utilizing clinical knowledge and experience, responsible for review of documentation to ensure medical necessity and appropriate level of care utilizing MCG/InterQual, state/federal guidelines, billing and coding regulations, and Molina policies; validates the medical record and claim submitted support correct coding to ensure appropriate reimbursement to providers. Must be willing to work a PST schedule. Duties include facilitating medical review of appeals for denied prior authorizations, retrospective medical claim reviews, and resolving escalated complaints regarding utilization management. Requires at least 2 years clinical nursing experience including 1 year of utilization review, medical claims review, or coding experience. Active RN license required; compact license acceptable where states allow.

Key responsibilities

  • Facilitate medical review of prospective, retrospective, and concurrent review of appeals for denied prior authorizations
  • Facilitate clinical/medical reviews of retrospective medical claim reviews and appeals
  • Reevaluate medical claims and associated records to assess appropriateness of services
  • Validate member medical records and claims submitted/correct coding
  • Resolve escalated complaints regarding utilization management and LTSS issues
  • Identify and report quality of care issues
  • Assist with complex claim review including DRG validation, itemized bill review
  • Prepare and present cases for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings
  • Review medically appropriate clinical guidelines with medical directors on denial decisions
  • Supply criteria supporting recommendations for denial or modification of payment decisions

What you bring

  • Active RN license (compact acceptable)
  • 2+ years clinical nursing experience
  • 1+ year utilization review, medical claims review, or coding experience
  • Knowledge of ICD-10, CPT, HCPC coding
  • Experience with state, federal, and third-party regulations
  • Analytic, problem-solving, decision-making skills
  • Organizational and time-management skills
  • Attention to detail
  • Critical-thinking and active listening skills
  • Effective verbal and written communication

Tags

100% RemotePST ScheduleAppeals ReviewUtilization ReviewMolina Healthcare

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