As a Medical Review Nurse, you will utilise your clinical knowledge and experience to review documentation, ensuring medical necessity and appropriate levels of care. Your role will involve validating medical records and claims to support correct coding, ultimately ensuring appropriate reimbursement for providers. Key Responsibilities of a Medical Review Nurse Facilitate medical review of prospective, retrospective, and concurrent appeals for denied prior authorizations, including standard and expedited cases, inpatient, outpatient, and pharmaceutical authorization appeals. Facilitate clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluate medical claims and associated records by applying advanced clinical knowledge, regulatory requirements, and Molina policies to assess the appropriateness of services, length of stay, level of care, and inpatient readmissions. Validate member medical records and claims submitted/correct coding to ensure appropriate reimbursement to providers. Resolve escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identify and report quality of care issues. Assist with complex claim review, including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and opportunities identified by the payment integrity analytical team. Prepare and present cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Review medically appropriate clinical guidelines and other criteria with medical directors on denial decisions. Supply criteria supporting all recommendations for denial or modification of payment decisions. Serve as a clinical resource for utilization management, CMOs, physicians, and member/provider inquiries/appeals. Provide training and support to clinical peers. Identify and refer members with special needs to the appropriate Molina program per applicable policies/protocols. What We Offer Competitive benefits package Competitive compensation package What We Offer Molina Healthcare offers a competitive benefits and compensation package to its employees, ensuring a supportive and rewarding work environment. Who We Are Looking For We are seeking a highly skilled and experienced Medical Review Nurse with a strong clinical background. The ideal candidate will possess at least two years of clinical nursing experience, including a minimum of one year in utilization review, medical claims review, or related fields. You must be a Registered Nurse with an active and unrestricted license, demonstrating expertise in ICD-10, CPT, and HCPC coding, as well as knowledge of relevant state and federal regulations. We value candidates with strong analytical, problem-solving, and communication skills, coupled with meticulous attention to detail and proficiency in essential software. At least 2 years of clinical nursing experience, including a minimum of 1 year in utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review, and/or coding experience, or an equivalent combination of education and experience. Registered Nurse (RN) with an active and unrestricted license in the state of practice (compact license acceptable where allowed). Demonstrated 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. Strong analytical, problem-solving, and decision-making skills. Excellent organizational and time-management abilities. Keen attention to detail. Critical-thinking and active listening skills. Proficiency in common look software. Effective verbal and written communication skills. Proficiency with Microsoft Office suite and applicable software program(s). Why Join Our Team? Purpose-driven culture focused on helping underserved communities Strong sense of meaning and purpose in your work Values integrity and absolute accountability Supportive teamwork environment Honest and open communication Member and community-focused approach Key Responsibilities of a Medical Review Nurse As a Medical Review Nurse, you will play a crucial role in ensuring medical necessity and appropriate billing, leveraging your clinical expertise to review documentation, facilitate appeals, and support accurate claims processing. This position is vital for maintaining high standards of care and fair reimbursement within a purpose-driven healthcare organisation.