Clinical Review Nurse Specialist
2 weeks ago
Position Summary
Utilizing extensive clinical expertise, the incumbent will be responsible for evaluating documentation to confirm medical necessity and the appropriate level of care in accordance with MCG/InterQual standards, state and federal regulations, billing and coding guidelines, as well as Molina policies. This role involves validating medical records and claims to ensure accurate coding, thereby facilitating proper reimbursement to healthcare providers.
Key Responsibilities
- Conducts thorough clinical reviews of retrospective medical claims, including previously denied cases where an appeal has been initiated, to ascertain medical necessity and ensure precise billing and claims processing.
- Identifies and escalates quality of care concerns.
- Assists in the review of complex claims, which may include DRG validation, itemized bill assessments, evaluations of appropriate levels of care, inpatient readmissions, and any opportunities identified by the Payment Integrity analytical team; this requires sound decision-making based on clinical experience.
- Documents findings from clinical reviews, bill audits, and audit specifics in the designated database.
- Provides comprehensive documentation to support denial and modification of payment decisions.
- Independently reassesses medical claims and associated records by applying advanced clinical knowledge, understanding of relevant federal and state regulations, Molina policies, and personal judgment to evaluate the appropriateness of services rendered, duration of stay, and level of care.
- Collaborates with Medical Directors to review clinically appropriate guidelines and criteria related to denial decisions.
- Supplies supporting criteria for all recommendations regarding denial or modification of payment decisions.
- Acts as a clinical resource for Utilization Management, Chief Medical Officers, Physicians, and inquiries/appeals from members/providers.
- Provides mentorship and support to clinical colleagues.
- Identifies and refers members with special needs to the appropriate Molina Healthcare programs as per established protocols.
Graduate from an accredited nursing program.
Required Experience, Knowledge, Skills & Abilities:
- At least 3 years of clinical nursing experience.
- A minimum of 1 year in Utilization Review and/or Medical Claims Review.
- At least 2 years of experience in Claims Auditing, Medical Necessity Review, and Coding.
- Familiarity with state and federal regulations.
Active, unrestricted State Registered Nursing (RN) license in good standing.
Preferred Education:
Bachelor's Degree in Nursing or a related health field.
Preferred Experience:
Nursing experience in Critical Care, Emergency Medicine, Medical Surgical, or Pediatrics. Advanced Practice Nursing. Experience in billing and coding.
Preferred Licensure and Certification:
Certified Clinical Coder, Certified Medical Audit Specialist, Certified Case Manager, Certified Professional in Healthcare Management, Certified Professional in Healthcare Quality, or other relevant healthcare certifications.
Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
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