Long Beach, California, United States · Hybrid
Job Description 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 inpati…
Skills: Medical Review, Utilization Review, Case Management, ICD-10 Coding, CPT Coding
Long Beach, California, United States · Hybrid
JOB DESCRIPTION This RN will act as a Care Manager 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 d…
Skills: Care Management, Case Management, Patient Assessment, Care Coordination, Motivational Interviewing
Long Beach, California, United States · Remote OK
$26/hr–$51/hr
JOB DESCRIPTION Job Summary Provides support for healthcare services clinical auditing activities. Performs audits for clinical functional areas in alignment with regulatory requirements - ensuring quality compliance and…
Skills: Clinical Auditing, Utilization Management, Care Management, Regulatory Compliance, Analytical Skills
Long Beach, California, United States · On-site
JOB DESCRIPTION Job Summary Provides deep subject matter expertise and leadership for Medicare Stars quality improvement (QI) programs and activities. Plans and implements QI initiatives and education programs to support…
Skills: Medicare Stars Program Management, Quality Improvement, Project Management, Data Analysis, Process Improvement
Long Beach, California, United States · Remote Solely
$23/hr–$51/hr
JOB DESCRIPTION **Fully remote opportunity requiring an active Illinois nursing license. The role operates Monday through Friday from 9:30 AM to 6:00 PM CST (30-minute lunch) or 9:00 AM - 6:00 PM CST (1 hour lunch) and r…
Skills: Utilization Management, MCG Guidelines, Clinical Review, Prior Authorization, Medical Necessity Assessment
Long Beach, California, United States · Hybrid
$26/hr–$51/hr
JOB DESCRIPTION This RN will act as a Care Review Clinician supporting our Medicaid members who have recently been admitted to this hospital. The Medicaid will support them to ensure a successful transition from inpatien…
Skills: Care Management, Case Management, Patient Assessment, Care Planning, Medication Reconciliation
Long Beach, California, United States · Hybrid
$26/hr–$51/hr
JOB DESCRIPTION Job Summary Provides support for care management/care coordination long-term services and supports (LTSS)-specific activities. Collaborates with multidisciplinary team coordinating integrated delivery of …
Skills: Care Management, Care Coordination, Member Assessment, Care Planning, Motivational Interviewing
Long Beach, California, United States · Remote OK
JOB DESCRIPTION Job Summary Provides senior level support for health plan provider relations activities. Supports network development, network adequacy and provider training and education. Serves as primary point of cont…
Skills: Provider Relations, Network Management, Customer Service, Training And Education, Issue Resolution
Long Beach, California, United States · On-site
$23/hr–$51/hr
EST applicants preferred. Ohio licensure required. Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with est…
Skills: Utilization Review, Clinical Assessment, Medical Necessity Verification, Prior Authorization, Case Management
Long Beach, California, United States · Hybrid
$22/hr–$46/hr
This is a remote field-based role requiring travel. Job Summary Provides support for care management/care coordination long-term services and supports (LTSS)-specific activities. Collaborates with multidisciplinary team …
Skills: Care Management, Care Coordination, Member Assessment, Care Planning, Waiver Enrollment
Long Beach, California, United States · Hybrid
$22/hr–$46/hr
This is remote field-based role requiring travel. Job Summary Provides support for care management/care coordination long-term services and supports (LTSS)-specific activities. Collaborates with multidisciplinary team co…
Skills: Care Management, Care Coordination, Member Assessment, Care Planning, Waiver Enrollment
Long Beach, California, United States · Remote OK
$12/hr–$26/hr
JOB DESCRIPTION Job Summary Provides support for pharmacy technician activities. Contributes to overarching pharmacy strategy for optimization of medication related health care outcomes, and quality cost-effective member…
Skills: Prior Authorization, Pharmacy Technician Activities, Medication Health Care Outcomes, HIPAA Compliance, Microsoft Office
Long Beach, California, United States · Remote OK
$23/hr–$51/hr
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insura…
Skills: Clinical Review, Utilization Management, Prior Authorization, Medical Necessity Assessment, Case Management
Long Beach, California, United States · Hybrid
$25/hr–$51/hr
JOB DESCRIPTION Job Summary Provides support for care management/care coordination activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum. Strives to …
Skills: Care Management, Care Coordination, Comprehensive Assessments, Motivational Interviewing, Medication Reconciliation
Long Beach, California, United States · On-site
JOB DESCRIPTION Opportunity for a Texas licensed RN to join Molina as a Field Care Manager to work with our Medicaid members in the service delivery area around Tyler, TX. You will complete assessments needed for determi…
Skills: Care Management, Member Assessments, Care Planning, Case Coordination, Motivational Interviewing
Long Beach, California, United States · On-site
JOB DESCRIPTION Job Summary Provides support for provider network administration activities. Responsible for accurate and timely validation and maintenance of critical provider information on all claims and provider data…
Skills: Provider Network Administration, Claims Processing, Data Entry, Customer Service, Microsoft Office
Long Beach, California, United States · On-site
JOB DESCRIPTION Job Summary Provides analyst support for configuration oversight activities. Responsible for accurate and timely implementation and maintenance of critical information on claims/provider databases, valida…
Skills: Claims Auditing, Configuration Oversight, Data Analysis, Microsoft Excel, VLOOKUP
Long Beach, California, United States · Remote OK
***Remote and must live in the United States*** JOB DESCRIPTION Job Summary Leads and directs team responsible for value-based programs (VBP) activities. Responsible for developing and implementing value-based strategies…
Skills: Value-Based Programs, Risk Adjustment, Managed Care, Contract Design, Medicaid
Long Beach, California, United States · On-site
JOB DESCRIPTION Job Summary Provides subject matter expertise and leadership for health plan provider network complex contracting activities. Supports network strategy and development with respect to adequacy, financial …
Skills: Provider Network Contracting, Contract Negotiation, Value-Based Payment, Financial Analysis, Relationship Management
Long Beach, California, United States · Remote OK
$60k–$130k/yr
JOB DESCRIPTION Job Summary Provides subject matter expertise for Molina’s risk and quality performance solutions (RQS) team. Collaborates with various departments and stakeholders across the enterprise to plan, coordina…
Skills: Program Management, Project Management, Risk Adjustment, HEDIS, Data Analysis
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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.
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.
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.
Molina Healthcare is a FORTUNE 500 company that is focused exclusively on government-sponsored health care programs for families and individuals who qualify for government sponsored health care. Molina Healthcare contracts with state governments and serves as a health plan providing a wide range of quality health care services to families and individuals. Molina Healthcare offers health plans in Arizona, California, Florida, Idaho, Illinois, Kentucky, Massachusetts, Michigan, Mississippi, Nevada, New Mexico, New York, Ohio, South Carolina, Texas, Utah, Virginia, Washington and Wisconsin. Molina also offers a Medicare product and has been selected in several states to participate in duals demonstration projects to manage the care for those eligible for both Medicaid and Medicare.
Offices: 200 Oceangate, Long Beach, California 90802, US
Molina Healthcare is a FORTUNE 500 company that is focused exclusively on government-sponsored health care programs for families and individuals who qualify for government sponsored health care. Molina Healthcare contracts with state governments and serves as a health plan providing a wide range of quality health care services to families and individuals. Molina Healthcare offers health plans in Arizona, California, Florida, Idaho, Illinois, Kentucky, Massachusetts, Michigan, Mississippi, Nevada, New Mexico, New York, Ohio, South Carolina, Texas, Utah, Virginia, Washington and Wisconsin. Molina also offers a Medicare product and has been selected in several states to participate in duals demonstration projects to manage the care for those eligible for both Medicaid and Medicare.
Offices: 200 Oceangate, Long Beach, California 90802, US
