RN Medical Claim Review Nurse Remote

Lensa is a career site that helps job seekers find great jobs in the US.We are not a staffing firm or agency.Lensa does not hire directly for these jobs, but promotes jobs on LinkedIn on behalf of its direct clients, recruitment ad agencies, and marketing partners.Lensa partners with DirectEmployers to promote this job for Molina Healthcare.Clicking Apply Now or Read more on Lensa redirects you to the job board / employer site.Any information collected there is subject to their terms and privacy notice.nnJob DescriptionnnJob SummarynnThe 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.nnFor 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.nnRemote positionnnWork hours :Monday - Friday 8 :00am - 5 :00pm.nnEssential Job DutiesnPerforms 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.nValidates member medical records and claims submitted / correct coding to ensure appropriate reimbursement to providers.nIdentifies and reports quality of care issues.nAssists 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.nFacilitates document management, clinical reviews, bill audit findings and audit details in the database.nProvides supporting documentation management for denial and modification of payment decisions.nIndependently 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.nReviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions.nSupplies criteria supporting all recommendations for denial or modification of payment decisions.nServes as a clinical resource for utilization management, chief medical officers, physicians and member / provider inquiries / appeals.nProvides training and support to clinical peers.nIdentifies and refers members with special needs to the appropriate Molina program per applicable policies / protocols.nCollaborates and / or leads special projects.nnRequired QualificationsnAt 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.nRegistered Nurse (RN).License must be active and unrestricted in state of practice.nExperience working within applicable state, federal, and third-party regulations.nStrong analytic and problem-solving abilities.nStrong organizational and time-management skills.nAbility to multi-task and meet deadlines.nAttention to detail.nCritical-thinking and active listening skills.- Common look proficiency.nDecision-making and problem-solving skills.nStrong verbal and written communication skills.nMicrosoft Office suite / applicable software program(s) proficiency, and ability to learn new programs.nnPreferred QualificationsnCertified 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.nNursing experience in critical care, emergency medicine, medical / surgical or pediatrics.nBilling and coding experience.nnTo all current Molina employees :If you are interested in applying for this position, please apply through the Internal Job Board.nnMolina Healthcare offers a competitive benefits and compensation package.Molina Healthcare is an Equal Opportunity Employer (EOE) M / F / D / VnnPay Range :$26.41 - $61.79 / HOURLYnActual compensation may vary from posting based on geographic location, work experience, education and / or skill level.nnIf you have questions about this posting, please contact [email protected]. Experience: 3 years required