Medical Review Nurse -UM/Post Appeals (Michigan RN license req)
Not Disclosed•Full-TimeOn-site
location_onOn-site
About the Role
This position serves as a critical clinical resource within Molina Healthcare's utilization management team. The role is designed to ensure the integrity of medical care delivery by leveraging advanced clinical knowledge to review documentation, validate medical necessity, and verify appropriate levels of care. You will act as a bridge between clinical practice and regulatory compliance, ensuring that reimbursement aligns with MCG/InterQual guidelines, state and federal regulations, and internal Molina policies.
In this capacity, you will facilitate comprehensive medical reviews for prospective, retrospective, and concurrent cases, including appeals for denied prior authorizations across inpatient, outpatient, and pharmaceutical settings. Your work directly impacts payment integrity by resolving escalated complaints, identifying quality of care issues, and supporting complex claim reviews involving DRG validation and readmission analysis. Additionally, you will represent Molina alongside the Chief Medical Officer in administrative law judge pre-hearings and judicial fair hearings, providing expert testimony and criteria supporting denial or modification decisions.
Beyond individual case management, you will serve as a mentor and trainer for clinical peers, offering guidance on utilization management protocols and referring members with special needs to appropriate Molina programs. This role requires a blend of analytical rigor, critical thinking, and effective communication to navigate complex regulatory landscapes while advocating for high-quality patient care.
Work location
Work model: On-site
On-site
Key Responsibilities
- check_circleFacilitate medical review of prospective, retrospective, and concurrent appeals for denied prior authorizations
- check_circleValidate member medical records and claims to ensure correct coding and appropriate reimbursement
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Frequently asked questions about Medical Review Nurse -UM/Post Appeals (Michigan RN license req) at Molina Healthcare
What does a Medical Review Nurse -UM/Post Appeals (Michigan RN license req) at Molina Healthcare do?expand_more
Day-to-day, the Medical Review Nurse -UM/Post Appeals (Michigan RN license req) at Molina Healthcare will facilitate medical review of prospective, retrospective, and concurrent appeals for denied prior authorizations; validate member medical records and claims to ensure correct coding and appropriate reimbursement; resolve escalated complaints regarding utilization management and long-term services and supports issues; and prepare and present cases for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings.
What are the requirements for this Medical Review Nurse -UM/Post Appeals (Michigan RN license req) role?expand_more
Molina Healthcare is looking for candidates who meet the following requirements: At least 2 years clinical nursing experience; At least 1 year utilization review, medical claims review, LTSS, claims auditing, medical necessity review, or coding experience; Registered Nurse (RN) license active and unrestricted in state of practice; Knowledge of ICD-10, CPT, and HCPC coding; Experience with state, federal, and third-party regulations; and Common Look proficiency.
Where is the Medical Review Nurse -UM/Post Appeals (Michigan RN license req) role at Molina Healthcare located?expand_more
Medical Review Nurse -UM/Post Appeals (Michigan RN license req) at Molina Healthcare is based in On-site. This is a on-site role.