Medical Claim Review Nurse (Registered Nurse MICHIGAN) Job at Molina Healthcare
For this position we are seeking a (RN) Registered Nurse, licensed for the state of MICHIGAN, with previous experience in Acute Care, case management, appeals, denials, Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines.
Excellent computer skills and attention to detail are very important to multi task between systems, talk with members on the phone, and enter accurate contact notes. Virtual office skills are necessary to be collaborative between team members using MS Teams, videoconference, voice conferencing and email/ chat communications. This is a fast paced position and productivity is important.
WORK SCHEDULE: Monday thru Friday 8:30AM to 5PM / 30 minute lunch break
This department operates 365 days a year and we need staff who can be flexible and willing to work some weekends and holidays. This is a remote position and you may work from home.
Further Details to be discussed during our interview process.
JOB DESCRIPTION
Job Summary
Responsible for administering claims payments, maintaining claim records, and providing counsel to claimants regarding coverage amount and benefit interpretation. Monitors and controls backlog and workflow of claims. Ensures that claims are settled in a timely fashion and in accordance with cost control standards.
KNOWLEDGE/SKILLS/ABILITIES
Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing.
Identifies and reports quality of care issues.
Identifies and refers members with special needs to the appropriate Molina Healthcare program per policy/protocol.
Assists with Complex Claim review; requires decision making pertinent to clinical experience
Documents clinical review summaries, bill audit findings and audit details in the database
Provides supporting documentation for denial and modification of payment decisions
Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care.
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, Chief Medical Officers, Physicians, and Member/Provider Inquiries/Appeals.
Provides training, leadership and mentoring for less experienced clinical peers and LVN, RN and administrative support staff.
Resolves escalated complaints regarding Utilization Management and Long-Term Services & Supports issues.
Identifies and reports quality of care issues.
Prepares and presents cases in conjunction with the Chief Medical Officers Medical Directors for Administrative Law Judge pre-hearings, State Insurance Commission, and Meet and Confers.
Represents Molina and presents cases effectively to Judicial Fair Hearing Officer during Fair Hearings as may be required.
JOB QUALIFICATIONS
Required Education
RN, BSN, or LCSW
Bachelor's Degree in Nursing or Health Related Field
Required Experience
Minimum three years clinical nursing experience.
Minimum one year Utilization Review and/or Medical
Claims Review.
Required License, Certification, Association
Active, unrestricted State Registered Nursing (RN) license in good standing.
Preferred Education
Master's Degree in Nursing or Health Related Field
Preferred Experience
Nursing experience in Critical Care, Emergency Medicine, Medical Surgical, or Pediatrics. Advanced Practice Nursing. Billing and coding experience.
Preferred License, Certification, Association
Certified Clinical Coder, Certified Medical Audit Specialists, Certified Case Manager, Certified Professional Healthcare Management, Certified Professional in Healthcare Quality or other healthcare certification.
Pay Range: $24.00 - 46.81 an hour*
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Please Note :
caminobluff.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, caminobluff.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, Site.com is the ideal place to find your next job.
Excellent computer skills and attention to detail are very important to multi task between systems, talk with members on the phone, and enter accurate contact notes. Virtual office skills are necessary to be collaborative between team members using MS Teams, videoconference, voice conferencing and email/ chat communications. This is a fast paced position and productivity is important.
WORK SCHEDULE: Monday thru Friday 8:30AM to 5PM / 30 minute lunch break
This department operates 365 days a year and we need staff who can be flexible and willing to work some weekends and holidays. This is a remote position and you may work from home.
Further Details to be discussed during our interview process.
JOB DESCRIPTION
Job Summary
Responsible for administering claims payments, maintaining claim records, and providing counsel to claimants regarding coverage amount and benefit interpretation. Monitors and controls backlog and workflow of claims. Ensures that claims are settled in a timely fashion and in accordance with cost control standards.
KNOWLEDGE/SKILLS/ABILITIES
Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing.
Identifies and reports quality of care issues.
Identifies and refers members with special needs to the appropriate Molina Healthcare program per policy/protocol.
Assists with Complex Claim review; requires decision making pertinent to clinical experience
Documents clinical review summaries, bill audit findings and audit details in the database
Provides supporting documentation for denial and modification of payment decisions
Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care.
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, Chief Medical Officers, Physicians, and Member/Provider Inquiries/Appeals.
Provides training, leadership and mentoring for less experienced clinical peers and LVN, RN and administrative support staff.
Resolves escalated complaints regarding Utilization Management and Long-Term Services & Supports issues.
Identifies and reports quality of care issues.
Prepares and presents cases in conjunction with the Chief Medical Officers Medical Directors for Administrative Law Judge pre-hearings, State Insurance Commission, and Meet and Confers.
Represents Molina and presents cases effectively to Judicial Fair Hearing Officer during Fair Hearings as may be required.
JOB QUALIFICATIONS
Required Education
RN, BSN, or LCSW
Bachelor's Degree in Nursing or Health Related Field
Required Experience
Minimum three years clinical nursing experience.
Minimum one year Utilization Review and/or Medical
Claims Review.
Required License, Certification, Association
Active, unrestricted State Registered Nursing (RN) license in good standing.
Preferred Education
Master's Degree in Nursing or Health Related Field
Preferred Experience
Nursing experience in Critical Care, Emergency Medicine, Medical Surgical, or Pediatrics. Advanced Practice Nursing. Billing and coding experience.
Preferred License, Certification, Association
Certified Clinical Coder, Certified Medical Audit Specialists, Certified Case Manager, Certified Professional Healthcare Management, Certified Professional in Healthcare Quality or other healthcare certification.
Pay Range: $24.00 - 46.81 an hour*
- Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Please Note :
caminobluff.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, caminobluff.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, Site.com is the ideal place to find your next job.