Medical Review Nurse -UM/Post Appeals (Michigan RN license req)
Not Disclosed•Full-TimeOn-site
location_onPlantation Road, Olive Green, Porter Township, Delaware County, Ohio, 43074, United States
About the Role
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 reimbursement accuracy. You will act as a bridge between clinical care, regulatory compliance, and financial stewardship, validating that services provided align with MCG/InterQual guidelines, state and federal regulations, and Molina's internal policies.
In this capacity, you will manage complex clinical reviews spanning prospective, retrospective, and concurrent phases. Your work directly impacts the quality of care and the financial health of provider partnerships by resolving escalated complaints, identifying quality of care issues, and ensuring appropriate billing and coding practices. You will also serve as a subject matter expert for medical directors, physicians, and peers, providing guidance on denial decisions and supporting the organization's commitment to high-quality healthcare delivery.
Work location
Work model: On-site
Plantation Road, Olive Green, Porter Township, Delaware County, Ohio, 43074, United States
Porter Township, Ohio
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 and judicial fair hearings.
What are the requirements for this Medical Review Nurse -UM/Post Appeals (Michigan RN license req) role?expand_more
To qualify for the Medical Review Nurse -UM/Post Appeals (Michigan RN license req) at Molina Healthcare position, applicants should have: 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 Plantation Road, Olive Green, Porter Township, Delaware County, Ohio, 43074, United States. This is a on-site role.