Medical Claim Review Nurse

Job Title

This role is fully remote and candidates should be in the following states: AZ, FL, , IA, GA, KY, MI, NE, NM, OH, TX, UT, WI, WA. The expected schedule is 9-5 PST Pacific time Zone, with alternate weekend rotations on Saturday and on-call Sunday.

Day to day responsibilities include utilizing clinical knowledge and experience to review documentation for medical necessity and appropriate level of care, applying MCG/Inter Qual, state/federal guidelines, billing and coding regulations, and Molina policies. The role also involves validating medical records and claims to ensure correct coding and appropriate reimbursement.

The position has potential to extend past 6 months and convert to a full-time equivalent (FTE). It facilitates medical review of prospective, retrospective, and concurrent review of appeals for denied prior authorizations, including standard and expedited cases, inpatient, outpatient, and pharmaceutical authorization appeals.

Additionally, the role involves clinical/medical reviews of retrospective medical claim reviews, medical claims, and previously denied cases to ensure medical necessity and accurate billing and claims processing. It also includes reevaluating medical claims and associated records, resolving escalated complaints, identifying and reporting quality of care issues, and assisting with complex claim reviews.

The position requires analytic, problem-solving, and decision-making skills, organizational and time-management skills, attention to detail, critical-thinking and active listening skills, common look proficiency, effective verbal and written communication skills, proficiency in Microsoft Office suite and applicable software programs, knowledge of ICD-10, Current Procedural Technology (CPT) coding, and Healthcare Common Procedure Coding (HCPC), and experience working within applicable state, federal, and third-party regulations.

Required experience includes at least 2 years clinical nursing experience, including at least 1 year of utilization review (prospective, retrospective and concurrent clinical review), medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Required licensure/education includes an active and unrestricted Registered Nurse (RN)/Licensed Practical Nurse (LPN) License in the state of practice.

Compact license is acceptable where states allow.