Medical Claim Review Nurse - Downers Grove, United States - Molina Healthcare

Molina Healthcare

Verified Company

Downers Grove, United States

3 weeks ago

Posted by:

Mark Lane

beBee recruiter

Description

This is a remote based position and you can work from home. Must work in the USA. COMPACT or MULTI STATE LICENSURE is very helpful to have for this role.

Job Summary

Utilizing clinical knowledge and experience, responsible for review of documentation to ensure medical necessity and appropriate level of care utilizing MCG/InterQual, state/federal guidelines, billing and coding regulations, and Molina policies; validates the medical record and claim submitted support correct coding to ensure appropriate reimbursement to providers.

Job Duties

Performs 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.

Identifies and reports quality of care issues.

Assists with Complex Claim review including DRG Validation, Itemized Bill Review, Appropriate Level of Care, Inpatient Readmission, and any opportunity identified by the Payment Integrity analytical team; requires decision making pertinent to clinical experience

Documents clinical review summaries, bill audit findings and audit details in the database

Provides supporting documentation for denial and modification of payment decisions

Reviews medically appropriate clinical guidelines and other appropriate criteria with Medical Directors on denial decisions.

Supplies criteria supporting all recommendations for denial or modification of payment decisions.

Serves as a clinical resource for Utilization Management, Chief Medical Officers, Physicians, and Member/Provider Inquiries/Appeals.

Provides training and support to clinical peers.

Identifies and refers members with special needs to the appropriate Molina Healthcare program per policy/protocol.

JOB QUALIFICATIONS
Graduate from an Accredited School of Nursing

REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:

Minimum 3 years clinical nursing experience.

Minimum one year Utilization Review and/or Medical Claims Review.

Minimum two years of experience in Claims Auditing, Medical Necessity Review and Coding experience

Familiar with state/federal regulations

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

Active, unrestricted State Registered Nursing (RN) license in good standing.

PREFERRED EDUCATION:

Bachelor's Degree in Nursing or Health Related Field

PREFERRED EXPERIENCE:

Nursing experience in Critical Care, Emergency Medicine, Medical Surgical, or Pediatrics. Advanced Practice Nursing. Billing and coding experience.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Certified Clinical Coder, Certified Medical Audit Specialists, Certified Case Manager, Certified Professional Healthcare Management, Certified Professional in Healthcare Quality or other healthcare certification.

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

Pay Range:
$ $51.49 / HOURLY