Medical Review Nurse (RN)

Medical Claims Review Support Provides support for medical claim and internal appeals review activities ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. Job duties include: Facilitating clinical/medical reviews of retrospective medical claim reviews, medical claims, and previously denied cases in which an appeal has been made or is likely to be made to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluating medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validating member medical records and claims submitted/correct coding to ensure appropriate reimbursement to providers. Resolving escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifying and reporting quality of care issues. Assisting with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; making decisions and recommendations pertinent to clinical experience. Preparing and presenting cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Reviewing medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. Supplying criteria supporting all recommendations for denial or modification of payment decisions. Serving as a clinical resource for utilization management, CMOs, physicians, and member/provider inquiries/appeals. Providing training and support to clinical peers. Identifying and referring members with special needs to the appropriate Molina program per applicable policies/protocols. Job qualifications: Required qualifications include: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review, and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding, and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. Preferred qualifications include: Certified 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 certifications. Nursing experience in critical care, emergency medicine, medical/surgical, or pediatrics. Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $67.97 / HOURLY Actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level.

Created: 2026-03-04