Medical Review Nurse in Lindon, UT

Job Summary

The Medical Review Nurse plays a critical role in supporting medical claim reviews and internal appeals, aligning with state and federal regulations, Molina policies, and clinical guidelines. This position aims to enhance quality and cost-effective care for our members.

We are seeking a skilled Registered Nurse with experience in Appeals to join our Appeals and Grievances department. Ideal candidates will possess strong organizational skills, advanced proficiency in MS Excel, the ability to navigate multiple screens, and overall computer literacy to thrive in our fast-paced environment. Further details will be discussed during the interview process.

This remote position prefers candidates based in Michigan, Illinois, or Wisconsin.

Work Hours: Monday - Friday: 8:30am - 5:00pm EST. Saturday on-call and holiday rotation required.

Licensing: A valid Michigan RN license is required.

Key Responsibilities
• Facilitate comprehensive clinical and medical reviews of medical claims and appeals to ensure medical necessity and correct billing.
• Reassess medical cases through clinical expertise and knowledge of regulations, ensuring appropriate levels of care and service provided.
• Verify accuracy of member medical records and claims submitted, ensuring correct coding for provider reimbursement.
• Address and resolve escalated complaints related to utilization management and long-term services and supports (LTSS).
• Identify, document, and report quality of care concerns.
• Assist in complex claim reviews, making informed decisions related to clinical findings and payment integrity issues.
• Prepare and present cases for administrative hearings in collaboration with the chief medical officer (CMO).
• Consult with medical directors on denial decisions, using medically appropriate guidelines.
• Offer clear criteria to justify denial or payment modification recommendations.
• Serve as a clinical resource for utilization management teams, CMOs, and member/provider inquiries.
• Provide training and support to clinical colleagues.
• Refer members with special needs to applicable Molina programs according to policies.

Qualifications

Required:
• Minimum of 2 years of clinical nursing experience, including at least 1 year in utilization review, medical claims review, or similar experience.
• Active and unrestricted Registered Nurse (RN) license.
• Experience with ICD-10, CPT coding, and HCPCS.
• Familiarity with state, federal, and third-party regulations.
• Strong analytical, problem-solving, and decision-making abilities.
• Excellent organizational and time-management skills.
• High attention to detail.
• Effective critical-thinking and active listening abilities.
• Proficient in Microsoft Office and other relevant software.

Preferred:
• Relevant healthcare certifications (e.g., CCC, CMAS, CCM, CPHM, CPHQ).
• Nursing experience in critical care, emergency medicine, or pediatrics.
• Background in medical billing and coding.

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

Pay Range: $29.05 - $67.97 / HOURLY. Actual compensation may vary based on location, experience, and skills.