- 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
- Independently 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.
- 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.
- 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
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Medical Claim Review Nurse - Downers Grove, United States - Molina Healthcare
Description
Job DescriptionWe are seeking a REGISTERED NURSE (RN) Medical Claims Review Nurse. Excellent computer skills including good MS Excel, analytics, sorting, and data entry is essential to be successful in this role. Virtual office skills are necessary to be collaborative between team members using MS Teams, videoconference, voice conferencing and email/ chat communications.
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 DESCRIPTION
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
Graduate from an Accredited School of Nursing
REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:
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.
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
