JOB DESCRIPTIONJob SummaryUtilizing 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.This position will be supporting our Appeals and Grievances department. We are seeking a Registered Nurse with previous claims and appeals experience. The candidate must have strong skills with organization, multitasking, problem solving, and using clinical judgment. Candidates with proficient knowledge of MS Office, PEGA, QNXT, MCG is highly preferred. Further details to be discussed during our interview process.This is a remote position.Illinois & Wisconsin RN compact licensure requiredWork hours: Monday- Friday: 8:30am -5:00pm. Central Time. Along with every 8 weeks Friday coverage is from 9 to 5:30pm CST for 2 weeks.Job Duties.
Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing.
Identifies and reports quality of care issues.
Assists with Complex Claim review including DRG Validation, Itemized Bill Review, Appropriate Level of Care, Inpatient Readmission, and any opportunity identified by the Payment Integrity analytical team; requires decision making pertinent to clinical experience
Documents clinical review summaries, bill audit findings and audit details in the database
Provides supporting documentation for denial and modification of payment decisions
Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care.
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, Chief Medical Officers, Physicians, and Member/Provider Inquiries/Appeals.
Provides training and support to clinical peers.
Identifies and refers members with special needs to the appropriate Molina Healthcare program per policy/protocol.
JOB QUALIFICATIONSGraduate from an Accredited School of NursingREQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:
Minimum 3 years clinical nursing experience.
Minimum one year Utilization Review and/or Medical Claims Review.
Minimum two years of experience in Claims Auditing, Medical Necessity Review and Coding experience
Familiar with state/federal regulations
REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:Active, unrestricted State Registered Nursing (RN) license in good standing.PREFERRED EDUCATION:Bachelors’s Degree in Nursing or Health Related FieldPREFERRED 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, Certified Medical Audit Specialists, Certified Case Manager , Certified Professional Healthcare Management, Certified Professional in Healthcare Quality or other healthcare certification.To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.Pay Range: $26.41 - $61.79 / HOURLYActual compensation may vary from posting based on geographic location, work experience, education and/or skill level.