Coding h1.location_city

Job Summary

Join our team as a Medical Appeal Nurse, where you'll play a critical role in supporting medical claim and internal appeals reviews. Your expertise will be essential in ensuring compliance with state and federal regulations, Molina policies, and clinical guidelines, all while contributing to the mission of providing quality, cost-effective care for our members.

Key Responsibilities

• Lead clinical reviews of retrospective medical claims, including previously denied cases, to assess medical necessity and ensure accurate billing and claims processing.
• Utilize your advanced clinical knowledge to reevaluate medical claims, interpreting regulations, Molina policies, and your clinical experience to determine the appropriateness of services provided.
• Ensure correct coding and reimbursement for providers by validating member medical records and claims.
• Address escalated complaints regarding utilization management and long-term services and supports (LTSS) issues.
• Identify and report any quality of care concerns that arise during reviews.
• Assist with complex claim reviews such as diagnosis-related group (DRG) validation, inpatient readmissions, and collaborate with the payment integrity analytical team to enhance decision-making.
• Prepare and represent cases alongside the chief medical officer for administrative law judge pre-hearings and state insurance commission hearings.
• Collaborate with medical directors to review medically appropriate clinical guidelines and support denial decision-making.
• Provide criteria and justifications for all recommendations regarding payment decisions.
• Act as a clinical resource for utilization management, CMOs, doctors, and inquiries from members or providers.
• Facilitate training and support for clinical peers to improve overall performance.
• Identify members with special needs and refer them to appropriate Molina programs as per guidelines.

Qualifications

Required:

• A minimum of 2 years of clinical nursing experience, including at least 1 year in utilization review or medical claims review.
• Current, active, and unrestricted RN license in your state of practice.
• Proficiency in ICD-10, CPT coding, and HCPC knowledge.
• Experience with state and federal regulations in healthcare.
• Strong analytical, problem-solving, and decision-making skills.
• Excellent organizational and time-management abilities, with a keen attention to detail.
• Critical-thinking skills combined with active listening capabilities.
• Proficient in Microsoft Office Suite and relevant software programs.

Preferred:

• Certifications such as Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), or Certified Professional in Healthcare Quality (CPHQ).
• Experience in critical care, emergency medicine, medical/surgical nursing, or pediatrics.
• Background in billing and coding is an advantage.

To all current Molina employees: If you are interested, please apply via the Internal Job Board. We offer a competitive benefits and compensation package, and we are proud to be an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $56.64 / HOURLY. *Compensation may vary based on geographic location, work experience, education, and skill level.