Medical Claim Review Nurse (RN)

JOB DESCRIPTION

Looking for a RN that has a current active unrestricted license

This a remote role and can sit anywhere within the United States.

Work Schedule Monday to Friday - operation hours 6 AM to 6 PM (Team will work on set schedule)

Looking for a RN with experience with appeals, claims review, and medical coding.

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

• 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.

Assists with Complex Claim review including DRG Validation, Itemized Bill Review, Appropriate Level of Care, Inpatient Readmission, and any opportunity identified by the