Job Summary
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.
Job Duties
- Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing.
- Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions in alignment with federal and state regulations and with health plan contracts.
- Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers.
- Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues.
- Identifies and reports quality of care issues.
- Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience in alignment with federal and state regulations and with health plan contracts.
- Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings.
- Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions.
- Supplies criteria supporting all recommendations for denial or modification of payment decisions.
- Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals.
- Provides training and support to clinical peers.
- Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols.