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RN Medical Claim Review Nurse Remote
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divh2Medical Claim Review Nurse/h2pThe Medical Claim Review Nurse provides support for medical claim review activities. Responsible for ensuring timely claims payment processes, providing counsel to members regarding coverage and benefit interpretation, and appropriate level of care for provision of member services in alignment with state, federal, accrediting, and billing/coding guidelines and regulations. Contributes to overarching strategy to provide quality and cost-effective member care. For this position we are seeking an RN with previous Inpatient Hospital, Skilled Nursing Facility experience, and outpatient coding experience including diagnosis. Candidates with knowledge of CPT/HCPCS codes, record review, chart audit, provider disputes, appeals, and 1500 UB04 claim experience are highly preferred. Ability to apply state and federal regulations based on specific state and line of business. Must be able to work in a fast paced environment with frequent updates to reviews and processes. Further details to be discussed during the interview process. Remote position Work hours: Monday - Friday 8:00am - 5:00pm./ppEssential Job Duties:/pulliPerforms clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing./liliValidates member medical records and claims submitted/correct coding to ensure appropriate reimbursement to providers./liliIdentifies and reports quality of care issues./liliAssists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunity identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience./liliFacilitates document management, clinical reviews, bill audit findings and audit details in the database./liliProvides supporting documentation management for denial and modification of payment decisions./liliIndependently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable federal and state regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care./liliReviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions./liliSupplies criteria supporting all recommendations for denial or modification of payment decisions./liliServes as a clinical resource for utilization management, chief medical officers, physicians and member/provider inquiries/appeals./liliProvides training and support to clinical peers./liliIdentifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols./liliCollaborates and/or leads special projects./li/ulpRequired Qualifications:/pulliAt least 2 years clinical nursing experience, preferably in a hospital setting, including at least 1 year of utilization review, medical claims review, claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience./liliRegistered Nurse (RN). License must be active and unrestricted in the state of practice./liliExperience working within applicable state, federal, and third-party regulations./liliStrong analytic and problem-solving abilities./liliStrong organizational and time-management skills./liliAbility to multi-task and meet deadlines./liliAttention to detail./liliCritical-thinking and active listening skills./liliCommon look proficiency./liliDecision-making and problem-solving skills./liliStrong verbal and written communication skills./liliMicrosoft Office suite/applicable software program(s) proficiency, and ability to learn new programs./li/ulpPreferred Qualifications:/pulliCertified 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 certification./liliNursing experience in critical care, emergency medicine, medical/surgical or pediatrics./liliBilling and coding experience./li/ulpMolina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V./ppPay Range: $26.41 - $61.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level./p/div
