Medical Review Nurse -UM/Post Appeals (Michigan RN license req)
Not Disclosed•Full-TimeOn-site
location_on791, West River Heights Avenue, River Haven, Tampa, Hillsborough County, Florida, 33603, United States
This position serves as a critical clinical resource within Molina Healthcare's utilization management team. The role leverages advanced nursing expertise to ensure the integrity of medical necessity determinations and appropriate levels of care. By applying clinical knowledge alongside MCG/InterQual guidelines, state and federal regulations, and internal policies, the incumbent validates medical records and claims to support accurate coding and reimbursement for providers.
The role is pivotal in maintaining the balance between quality patient care and fiscal responsibility. You will facilitate comprehensive medical reviews for prospective, retrospective, and concurrent cases, handling appeals for denied prior authorizations across inpatient, outpatient, and pharmaceutical settings. A key aspect of the day-to-day involves reevaluating complex claims, including DRG validation and itemized bill reviews, to identify opportunities for payment integrity and ensure compliance with regulatory standards.
Beyond individual case management, this role acts as a bridge between clinical operations and leadership. You will collaborate with Chief Medical Officers (CMOs) and medical directors to review denial decisions and present complex cases for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Additionally, you will serve as a mentor to clinical peers, providing training and support while identifying members with special needs for appropriate Molina programs.
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. We are committed to fostering a diverse and inclusive workplace where all employees can thrive.
Work model: On-site
791, West River Heights Avenue, River Haven, Tampa, Hillsborough County, Florida, 33603, United States
Tampa, Florida
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.
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