Medical Review Nurse (RN) Remote

This RN will act as a Medical Review Nurse supporting our AZ Medicaid members who have recently been admitted to this hospital. The Medicaid will support them to ensure a successful transition from inpatient to discharge to either a nursing facility or back to their home. The position is a combination of phone call outreach and in person meetings with the members while still inpatient. Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. 

This is a telephonic position and productivity is important. Preferred candidates will have previous case management, managed care, or inpatient hospital experience. Experience in a behavioral health setting would be a plus. 

TRAVEL in the field to designated hospitals in the local service delivery area to meet with the members. Mileage is reimbursed as part of our benefit package.

Schedule: Monday through Friday 7:00AM to 6:00PM PST (No weekends, no nights, no holidays, no call.) Alternative work schedule ava after 6 month exp: 9am 0r 10 am 6pm

Utilizing clinical knowledge and experience, responsible for review of documentation to ensure medical necessity and appropriate level of care utilizing MCG/InterQual, state/federal guidelines, billing and coding regulations, and Molina policies; validates the medical record and claim submitted support correct coding to ensure appropriate reimbursement to providers. 

•    Facilitates medical review of prospective, retrospective, and concurrent review of appeals for denied prior authorizations. Includes standard and expedited cases, inpatient, outpatient, and pharmaceutical authorization appeals.
•    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 advanced clinical 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 quality of care issues.
•    Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience.
•    Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings.                                                                
•    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, 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.

•    At least 2 years clinical nursing experience, including at least 1 year of utilization review (prospective, retrospective and concurrent clinical 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 Nurse (RN). License must be active and unrestricted in state of practice.  Compact license is acceptable where states allow.
•    Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and
•    Healthcare Common Procedure Coding (HCPC).
•    Experience working within applicable state, federal, and third-party regulations.
•    Analytic, problem-solving, and decision-making skills.              
•    Organizational and time-management skills.
•    Attention to detail.
•    Critical-thinking and active listening skills. 
•    Common look proficiency.
•    Effective verbal and written communication skills.
•    Microsoft Office suite and applicable software program(s) proficiency.

•    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.