Nurse Reviewer (RN) in Clearfield, UT

Job Summary Join our dedicated team as a Nurse Reviewer, where you will play a crucial role in supporting medical claim and internal appeal reviews. Your expertise will ensure compliance with relevant state and federal regulations, Molina policies, and clinical guidelines, all while contributing to a strategy focused on delivering high-quality and cost-effective care for our members. Key Responsibilities • Lead comprehensive clinical reviews of retrospective medical claims, appeals, and previously denied cases to confirm medical necessity and correct billing practices. • Evaluate medical claims and related records using advanced clinical knowledge to assess service appropriateness, length of stay, level of care, and readmissions. • Validate medical records and claims to ensure accurate coding and appropriate reimbursement for providers. • Address escalated complaints concerning utilization management and long-term services and supports (LTSS) issues. • Identify and report quality of care concerns. • Assist with complex claims reviews, including DRG validation, itemized bill reviews, and opportunities identified by the payment integrity analytical team. • Prepare and present cases for administrative law judge pre-hearings and state insurance commissions alongside the chief medical officer. • Review clinical guidelines regularly with medical directors regarding denial decisions. • Support all recommendations for denial or modification of payment decisions with solid criteria. • Act as a clinical resource for utilization management, CMOs, physicians, and address member/provider inquiries. • Provide training and mentorship to clinical colleagues. • Identify and refer members with special needs to appropriate Molina programs per policy and protocols. Qualifications Required: • A minimum of 2 years of clinical nursing experience, including at least 1 year in utilization review, medical claims review, or related fields. • Current and unrestricted Registered Nurse (RN) license in your state. • Knowledgeable in ICD-10, CPT coding, and HCPC. • Experience working within relevant regulations. • Strong analytical, problem-solving, and decision-making abilities. • Excellent organizational and time-management skills. • Heightened attention to detail. • Effective critical thinking and listening capabilities. • Proficient in Microsoft Office and relevant software. Preferred: • Relevant certifications such as Certified Clinical Coder (CCC) or Certified Professional Healthcare Management (CPHM). • Experience in critical care, emergency medicine, or pediatrics. • Background in billing and coding. If you're passionate about making a difference and meet the qualifications, we encourage you to apply to join Molina Healthcare, an Equal Opportunity Employer (EOE) M/F/D/V. We offer a competitive benefits package. Pay Range: $29.05 - $67.97 per hour. Note that actual compensation may vary based on geographic location, work experience, education, and skills.