Medical Review Nurse -UM/Post Appeals (Michigan RN license req)
Not Disclosed•Full-TimeOn-site
location_on2110, Griswold Lane, Austin, Travis County, Texas, 78703, 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 internal policies.
In this capacity, you will facilitate comprehensive reviews of prospective, retrospective, and concurrent cases, including appeals for denied prior authorizations across inpatient, outpatient, and pharmaceutical settings. Your work ensures that member medical records and claims are accurately coded and supported, directly impacting appropriate provider reimbursement and the quality of care delivered.
Day-to-Day Impact
Your day involves reevaluating complex medical claims and associated records to assess the appropriateness of services, length of stay, and level of care. You will resolve escalated complaints regarding utilization management and long-term services and supports (LTSS), while identifying and reporting quality of care issues. A significant portion of the role involves collaborating with Medical Directors to review clinical guidelines and denial decisions, supplying the necessary criteria to support recommendations for payment modifications or denials.
You will also serve as a subject matter expert for the Chief Medical Officer (CMO), physicians, and members, assisting with complex claim reviews such as DRG validation and itemized bill analysis. Additionally, you may prepare and present cases for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings, ensuring Molina's position is clearly articulated.
Hiring Process
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Our Commitment to Diversity
Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. We are committed to building a diverse workforce and providing a supportive environment where all employees can thrive.
Work location
Work model: On-site
2110, Griswold Lane, Austin, Travis County, Texas, 78703, United States
Austin, Texas
Key Responsibilities
- check_circleFacilitate medical review of prospective, retrospective, and concurrent appeals for denied prior authorizations
- check_circleReevaluate medical claims by applying advanced clinical knowledge and regulatory guidelines to assess level of care
- check_circleValidate member medical records and claims to ensure correct coding and appropriate provider reimbursement
- check_circleResolve escalated complaints regarding utilization management and long-term services and supports issues
- check_circlePrepare and present cases for administrative law judge pre-hearings and judicial fair hearings
- check_circleReview clinical guidelines with medical directors to support denial decisions
- check_circleProvide training and support to clinical peers
- check_circleConduct clinical reviews of medical claims and previously denied cases to ensure medical necessity and accurate billing
Requirements
- verifiedAt least 2 years clinical nursing experience
- verifiedAt least 1 year utilization review, medical claims review, LTSS, claims auditing, medical necessity review, or coding experience
- verifiedRegistered Nurse (RN) license active and unrestricted in state of practice
- verifiedKnowledge of ICD-10, CPT, and HCPC coding
- verifiedExperience with state, federal, and third-party regulations
- verifiedMicrosoft Office suite proficiency
Nice to Have
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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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
A Medical Review Nurse -UM/Post Appeals (Michigan RN license req) at Molina Healthcare is responsible for the following: Facilitate medical review of prospective, retrospective, and concurrent appeals for denied prior authorizations; Reevaluate medical claims by applying advanced clinical knowledge and regulatory guidelines to assess level of care; Validate member medical records and claims to ensure correct coding and appropriate provider reimbursement; and Resolve escalated complaints regarding utilization management and long-term services and supports issues.
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 Microsoft Office suite 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 2110, Griswold Lane, Austin, Travis County, Texas, 78703, United States. This is a on-site role.
Is this Medical Review Nurse -UM/Post Appeals (Michigan RN license req) job remote, hybrid, or on-site?expand_more
Molina Healthcare has listed this Medical Review Nurse -UM/Post Appeals (Michigan RN license req) role as on-site.
How much experience is required for this Medical Review Nurse -UM/Post Appeals (Michigan RN license req) role?expand_more
Medical Review Nurse -UM/Post Appeals (Michigan RN license req) at Molina Healthcare typically requires 2+ years of relevant experience at the mid level level.
What skills do you need for the Medical Review Nurse -UM/Post Appeals (Michigan RN license req) role at Molina Healthcare?expand_more
Key skills for Medical Review Nurse -UM/Post Appeals (Michigan RN license req) at Molina Healthcare include Utilization Review; Medical Claims Review; Long-Term Services And Supports; Claims Auditing; Medical Necessity Review; Coding; Icd-10; and Current Procedural Technology.
What category does the Medical Review Nurse -UM/Post Appeals (Michigan RN license req) role belong to?expand_more
Medical Review Nurse -UM/Post Appeals (Michigan RN license req) at Molina Healthcare is part of the healthcare & nursing job category on Recrutus.