Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. 

• 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, 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. 
• 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.