Clinical Review Nurse

Job Summary Join our dedicated team as a Clinical Review Nurse, where you will play a crucial role in ensuring quality and cost-effective member care. This position involves providing detailed support for medical claims and internal appeals reviews, ensuring compliance with both state and federal regulations as well as Molina policies. Key Responsibilities Conduct thorough clinical and medical reviews of retrospective claims and appeals to ascertain medical necessity and optimal billing practices. Reevaluate claims and medical records, utilizing your advanced clinical expertise to assess service appropriateness, length of stay, level of care, and readmission rates. Ensure correct coding and validate medical records, facilitating appropriate reimbursement processes for healthcare providers. Address complex complaints related to utilization management and long-term services, ensuring timely and effective resolutions. Identify and report any quality of care issues, contributing to continuous improvement in member healthcare. Assist with intricate claims reviews, including DRG validations and itemized bill assessments, making clinical decisions based on your extensive experience. Represent Molina in administrative hearings alongside the chief medical officer, preparing and presenting detailed cases. Collaborate with medical directors to review clinical guidelines impacting denial decisions. Provide thorough support for all recommendations involving payment modifications or denials. Act as a clinical expert for inquiries from utilization management, CMOs, physicians, and members/providers. Deliver training and guidance to clinical colleagues, enhancing team effectiveness. Identify and connect members with special needs to suitable Molina programs in alignment with established policies. Qualifications Required: Minimum 2 years of clinical nursing experience, with at least 1 year dedicated to utilization review, claims auditing, and/or medical necessity assessment. Current, unrestricted Registered Nurse (RN) license in your state of practice. Proficient knowledge of ICD-10, CPT coding, and HCPC regulations. Experience navigating state, federal, and third-party regulations relevant to healthcare. Strong analytical, problem-solving, and decision-making abilities. Exceptional organizational and time-management skills with keen attention to detail. Critical-thinking capabilities and effective active listening skills. Proficient in common software applications, including Microsoft Office Suite. Preferred: Certification as a Clinical Coder (CCC), Medical Audit Specialist (CMAS), Case Manager (CCM), Professional Healthcare Manager (CPHM), or in Healthcare Quality (CPHQ), among others. Nursing background in critical care, emergency medicine, or pediatrics. Experience with billing and coding processes. Note: If you’re currently employed at Molina and interested in this role, please apply through the Internal Job Board. Molina Healthcare offers a competitive compensation and benefits package. We are 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: 2026-03-10