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. Duties include facilitating medical review of prospective, retrospective, and concurrent review of appeals for denied prior authorizations; facilitating clinical/medical reviews of retrospective medical claim reviews; reevaluating medical claims and associated records; validating member medical records and claims; resolving escalated complaints; identifying and reporting quality of care issues; assisting with complex claim review; preparing and presenting cases for administrative law judge pre-hearings; reviewing clinical guidelines with medical directors; supplying criteria for denial decisions; serving as a clinical resource; providing training and support; and identifying members for special programs.
Tags
More open utilization review positions — or browse every utilization review role.