Medical Review Nurse (RN)

Molina Healthcare • Rochester, NY • 5d ago

Job Description

Job Summary

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care.

Job Duties

Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing.

Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions.

Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers.

Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues.

Identifies and reports quality of care issues.

Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience.

Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings.

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, CMOs, physicians and member/provider inquiries/appeals.

Provides training and support to clinical peers.

Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols.

Job Qualifications

REQUIRED QUALIFICATIONS:

At least 2 years clinical nursing experience, including at least 1 year of utilization 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.

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

Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC).

Experience working within applicable state, federal, and third-party regulations.

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.

Microsoft Office suite and applicable software program(s) proficiency.

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 health care certifications.

Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics.

Billing and coding experience.

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $29.05 - $67.97 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Similar Jobs

Nurse Recruiter

Highland Hospital • Rochester, NY • 1h ago

Hospital & Medical

17958BR Title: Nurse Recruiter Department/Cost Center: 631 - Recruitment Management Job Description: The nurse recruiter is responsible for the outreach and sourcing of candidates to build an applicant pool for positions...

1h ago

Go to Apply

Nurse Recruiter

Highland Hospital • Rochester, NY • 1h ago

Hospital & Medical

17957BR Title: Nurse Recruiter Department/Cost Center: 631 - Recruitment Management Job Description: The nurse recruiter is responsible for the outreach and sourcing of candidates to build an applicant pool for positions...

1h ago

Go to Apply

GYN Medical Assistant

Trillium Health NY • Rochester, NY • 11h ago

Hospital & Medical

Job Title: Medical Assistant Department: Clinic Position @type: Full Time 37.5 Hours FLSA: Non-Exempt Job Summary: As part of the clinical care team, the Medical Assistant plays a key role in preparing patients for exams...

11h ago

Go to Apply

Registered Nurse - Patient Aligned Care Team (PACT)

Veterans Affairs, Veterans Health Administration • Rochester, NY • 1d ago

Hospital & Medical

Summary The Finger Lakes VA Healthcare System has 1 vacancy for a Registered Nurse in the Rochester Clinic within the Patient Aligned Care Team (PACT) department. The RN delivers fundamental knowledge-based care to assig...

1d ago

Go to Apply

Manager, Nursing

Trillium Health NY • Rochester, NY • 1d ago

Hospital & Medical

Job Title: Manager, RN Department: Clinic FLSA: Non-Exempt Reports to: Director of Nursing Direct reports: No Overview: Join us and be part of a mission-driven team that champions innovation, collaboration, and continuou...

1d ago

Go to Apply

Registered Nurse

Heritage Christian Services • Rochester, NY • 1d ago

Hospital & Medical

Overview The Registered Nurse (RN) functions under the general supervision of the Nursing Support Specialist (NSS) while exercising independent professional judgment to deliver high-quality, person-centered care to indiv...

1d ago

Go to Apply

Physical Therapist 2

University of Rochester • Rochester, NY • 2d ago

Hospital & Medical

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability....

2d ago

Go to Apply

Nurse Practitioner

Amergis • Rochester, NY • 3d ago

Hospital & Medical

The Nurse Practitioner provides health care services to patients within scope of license, performs physical examinations and diagnostic tests, assessments and screenings, prescribes medications, and instructs patients an...

3d ago

Go to Apply

Admitting Clinical Coordinator

Highland Hospital • Rochester, NY • 3d ago

Hospital & Medical

17938BR Title: Admitting Clinical Coordinator Department/Cost Center: 844 - Admitting Job Description: *Highland Hospital is seeking a full time Admitting Clinical Coordinator. This is a Salaried position, working rotati...

3d ago

Go to Apply

Assistant Professor of Clinical

University of Rochester • Rochester, NY • 4d ago

Hospital & Medical

University of Rochester: Office of the Provost: University of Rochester Medical Center: School of Medicine and Dentistry: Anesthesiology & Perioperative Medicine Salary Range or Pay Grade 15.50 - 240.38 Description T...

4d ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.