Medical Review Nurse; RN Remote, Time Zone

Position: Medical Review Nurse (RN) Remote, 8:30am-5:00pm Central Time Zone Medical Review Nurse (RN) Remote, 8:30am-5:00pm Central Time Zone AZ, United States and 89 more Trending

Job Description

Job Description Job Summary 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

• Facilitates 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.
• Reevaluates 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.
• Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers.
• Resolves escalated complaints regarding utilization management and LTSS issues.
• 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 opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience.
• Prepares and presents cases representing Molina, along with the CMO, for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings.
• 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, CMOs, physicians and member/provider inquiries/appeals.
• Provides training and support to clinical peers.
• Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols.

Job Qualifications REQUIRED QUALIFICATIONS:

• At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, 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, CPT coding and HCPCS.
• Experience working within applicable state, federal, and third-party regulations.
• Analytic, problem-solving, and decision-making skills.
• Organizational and time-management skills.
• Critical-thinking and active listening skills.
• Effective verbal and written communication skills.
• Microsoft Office suite and applicable software program(s) proficiency.

PREFERRED QUALIFICATIONS:

• 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. Job Info

• Job Identification 2035812
• Job Category Clinical
• Posting Date 01/28/2026, 05:42 PM
• Job Schedule Full time
• Locations 200 Oceangate, Long Beach, CA, 90802, US

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