Medical Review Nurse

About the Medical Review Nurse Role at Molina Healthcare

The Medical Review Nurse provides essential support for medical claim and internal appeals review activities at Molina Healthcare. This role ensures strict alignment with applicable state and federal regulatory requirements, Molina policies, and medically appropriate clinical guidelines, ultimately contributing to a strategy focused on quality and cost-effective member care.

Key Responsibilities

• Facilitate clinical/medical reviews of retrospective medical claim reviews, medical claims, and previously denied cases for appeals, ensuring medical necessity and accurate billing/claims processing.
• Reevaluate medical claims and associated records using advanced clinical knowledge, regulatory guidelines, Molina policies, and individual judgment to assess service appropriateness, length of stay, level of care, and inpatient readmissions.
• Validate member medical records and claims submitted, including correct coding, to ensure appropriate provider reimbursement.
• Resolve escalated complaints concerning utilization management and long-term services and supports (LTSS) issues.
• Identify and report quality of care issues.
• Assist with complex claim reviews, including DRG validation, itemized bill review, appropriate level of care, inpatient readmission, and opportunities identified by the payment integrity team, making clinical decisions and recommendations.
• Prepare and present cases representing Molina, alongside the Chief Medical Officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings.
• Review medically appropriate clinical guidelines and other criteria with medical directors on denial decisions.
• Supply criteria supporting all recommendations for denial or modification of payment decisions.
• Serve as a clinical resource for utilization management, CMOs, physicians, and member/provider inquiries/appeals.
• Provide training and support to clinical peers.
• Identify and refer members with special needs to the appropriate Molina program per applicable policies/protocols.

Required Qualifications

• At least 2 years of clinical nursing experience, including a minimum of 1 year in utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review, and/or coding experience, or an equivalent combination of relevant education and experience.
• Active and unrestricted Registered Nurse (RN) license in the state of practice.
• Demonstrated knowledge of ICD-10, Current Procedural Technology (CPT) coding, and Healthcare Common Procedure Coding (HCPC).
• Experience working with applicable state, federal, and third-party regulations.
• Strong analytic, problem-solving, and decision-making skills.
• Excellent organizational and time-management skills.
• Exceptional attention to detail.
• Proficiency in critical-thinking and active listening skills.
• Common look proficiency.
• Effective verbal and written communication skills.
• Proficiency with Microsoft Office suite and applicable software programs.

Preferred Qualifications

• Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other relevant healthcare certifications.
• Nursing experience in critical care, emergency medicine, medical/surgical, or pediatrics.
• Billing and coding experience.

Key Skills/Competency

• Clinical Nursing
• Utilization Review
• Medical Claims Review
• Regulatory Compliance
• ICD-10/CPT/HCPC Coding
• Medical Necessity
• Problem-Solving
• Critical Thinking
• Communication
• Time Management