Medical Review Nurse; RN- Post Appeals; licensed

The Medical Review Nurse (RN) is responsible for reviewing documentation to ensure medical necessity and appropriate levels of care, utilizing clinical knowledge and experience. This role is ideal for those with a strong background in nursing and utilization review.

Pay: $30 - $59/hour

Location:

Remote, US

Schedule:

Full Time

• 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 previously denied cases.
• Reevaluate medical claims and associated records to assess appropriateness of services provided.
• Validate member medical records and claims submitted for 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 and itemized bill review.
• Prepare and present cases for administrative law judge pre-hearings and state insurance commissions.
• Review clinically appropriate guidelines with medical directors on denial decisions.
• Serve as a clinical resource for utilization management and member/provider inquiries.

• Registered Nurse (RN). License must be active and unrestricted in the state of practice.

• At least 2 years clinical nursing experience, including 1 year of utilization review, medical claims review, or equivalent.

• Current RN License in Illinois.
• Experience with ICD-10, CPT coding, and HCPC.

Molina Healthcare is a leading healthcare provider committed to delivering exceptional patient care. They focus on providing quality health services to those in need, ensuring access to necessary medical resources.