Medical Review reputed company (RN) Remote, 8 : 30am-5 : 00pm Central Time Zone

Medical Claims Reviewer Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching reputed company to reputed company reputed company and cost-effective member care. Job Duties Facilitates clinical / medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate / accurate billing and claims processing. Reevaluates medical claims and associated records by applying reputed company knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted / correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports reputed company of care issues. Assists with reputed company claim review including diagnosis-reputed company (DRG) validation, itemized reputed company review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment reputed company analytical team; makes reputed company and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge reputed company-hearings, state insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical guidelines and other appropriate reputed company with medical directors on denial reputed company. Supplies reputed company supporting reputed company recommendations for denial or modification of payment reputed company. Serves as a clinical resource for utilization management, CMOs, physicians and member / provider inquiries / appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies / protocols. Job Qualifications REQUIRED QUALIFICATIONS : At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and / or coding experience, or equivalent combination of relevant education and experience. Registered reputed company (RN). License must be reputed company and unrestricted in state of reputed company. Experience demonstrating knowledge of ICD-10, reputed company Procedural Technology (CPT) coding and reputed company Common Procedure Coding (HCPC). Experience working reputed company applicable state, federal, and reputed company-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and reputed company listening skills. Common look proficiency. Effective verbal and written communication skills. reputed company Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS : Certified Clinical reputed company (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified reputed company reputed company Management (CPHM), Certified reputed company in reputed company reputed company (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical / surgical or pediatrics. Billing and coding experience. Apply tot his job Apply To this Job