Clinical Review Nurse (RN) in Vineyard, UT

Job Description Job Summary As a Clinical Review Nurse, you will play a vital role in ensuring that medical claims and internal appeals are reviewed thoroughly in accordance with state and federal regulations, as well as Molina's policies. Your expertise will contribute significantly to the strategy of delivering high-quality, cost-effective care to our members. Key Responsibilities • Conduct comprehensive clinical reviews of medical claims, focusing on retrospective reviews and previously denied cases to ensure medical necessity and proper billing practices. • Evaluate medical records and claims using advanced clinical knowledge, regulatory requirements, Molina policies, and personal experience to assess the appropriateness of services provided and the length of stay. • Ensure the accuracy of coding and member medical records for correct provider reimbursement. • Address and resolve escalated complaints regarding utilization management and long-term services and supports. • Identify and articulate quality of care issues for reporting and action. • Engage in complex claim reviews, including diagnosis-related group validation and opportunities flagged by the payment integrity team, providing insightful recommendations based on clinical experience. • Prepare and represent cases for administrative hearings alongside the Chief Medical Officer. • Collaborate with medical directors on denial decisions based on medically appropriate guidelines. • Support clinical decision-making by supplying documentation for all recommendations regarding claims adjustments. • Serve as a clinical resource for inquiries from utilization management, physicians, and members/providers. • Mentor and train clinical colleagues within the organization. • Identify members with special needs and refer them to appropriate Molina programs, following established protocols. Qualifications Required Qualifications: • A minimum of 2 years of clinical nursing experience, including at least 1 year in utilization review, medical claims review, or related fields. • Current, active RN license in good standing. • Proficiency in ICD-10, CPT coding, and HCPCS. • Experience navigating state and federal healthcare regulations. • Strong analytic, problem-solving, and decision-making capabilities. • Excellent organizational and time management skills. • Meticulous attention to detail and strong critical thinking abilities. • Effective verbal and written communication skills. • Proficient in Microsoft Office and relevant software applications. Preferred Qualifications: • Professional certifications such as CCC, CMAS, CCM, CPHM, or CPHQ. • Nursing experience in critical care, emergency medicine, or other specialized fields. • Experience in billing and coding processes. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. We offer a competitive benefits and compensation package. Pay Range: $29.05 - $67.97 / HOURLY. Actual compensation may vary based on geographic location, experience, education, and skill level.