Remote RN Medical Claims Review Specialist

Job Summary: The Medical Claims Review Specialist plays a vital role in the medical claim review process. In this position, you will ensure timely claims payment, provide guidance on coverage and benefit interpretation, and support member services in accordance with state and federal regulations. We are seeking an experienced RN with a solid background in inpatient hospital care and outpatient coding, particularly in diagnosis-related contexts. Key Responsibilities: • Conduct clinical reviews of retrospective medical claims and previously denied cases to verify medical necessity and appropriate billing. • Validate member medical records and submitted claims to ensure correct coding and provider reimbursement. • Identify and escalate quality of care issues as necessary. • Review complex claims, including DRG validation and inpatient admissions, using your clinical expertise to make informed decisions. • Manage documentation and clinical reviews efficiently in our database. • Reassess medical claims using your clinical knowledge and familiarity with relevant regulatory guidelines to determine the appropriateness of services. • Engage with medical directors regarding denial decisions and supply supporting documentation for any payment modifications. • Serve as a clinical resource for medical inquiries and provide training for clinical peers. • Refer members with special needs to appropriate programs as per company protocols. • Lead and collaborate on special projects as needed. Qualifications: • Minimum of 2 years of clinical nursing experience, including at least 1 year in utilization review or medical claims review. • Active and unrestricted Registered Nurse (RN) license in your state. • Experience with applicable state, federal, and third-party regulations. • Proven analytical and problem-solving skills. • Strong organizational skills and able to manage multiple tasks to meet deadlines. • Exceptional attention to detail and critical-thinking capabilities. • Effective verbal and written communication skills. • Proficiency in Microsoft Office suite and ability to learn new software. Preferred Qualifications: • Certifications such as Certified Clinical Coder (CCC) or Certified Medical Audit Specialist (CMAS). • Experience in critical care, emergency medicine, or pediatrics. • Background in billing and coding. Work Environment: This is a remote position with work hours from Monday to Friday, 8:00 am to 5:00 pm. Compensation: Molina Healthcare offers a competitive salary range of $26.41 - $61.79 per hour, with actual compensation varying based on geographic location, experience, education, and skills. Apply tot his job Apply To this Job