Molina Healthcare·Long Beach, California
Responsible for conducting medical reviews of documentation to ensure medical necessity and appropriate level of care for Medicaid members. This includes managing appeals, validating medical records for correct coding, and facilitating transitions from inpatient to discharge.
This RN will act as a Medical Review Nurse supporting our Medicare claims and appeals. Excellent computer skills and attention to detail are very important to multitask between systems and enter accurate contact notes. This is a remote position and productivity is important. Preferred candidates will have previous utilization management, appeals and grievances, managed care, or inpatient hospital experience. Experience in a behavioral health setting would be a plus.
Job Summary 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. Job Duties
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. Job Qualifications REQUIRED QUALIFICATIONS:
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.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Requires a Registered Nurse license and at least 2 years of clinical nursing experience, including 1 year in utilization or claims review. Proficiency in ICD-10, CPT, and HCPC coding is essential.
Market context
Administrative roles in California healthcare and social services often draw steady demand because organizations need staff who can coordinate operations, support teams, and manage patient- or client-facing workflows. These positions are competitive when employers seek a bachelor’s degree, several years of relevant experience, strong Microsoft Office skills, and clear communication, along with screening requirements such as a background check and TB test. Review the AI-summarized requirements and benefits on this platform to save research time, then confirm your experience matches the posting before applying.