Remote RN Medical Claims Review Specialist

Job Summary The Remote RN Medical Claims Review Specialist plays a vital role in the medical claim review process, ensuring that claims are assessed and resolved in a timely manner. You will provide guidance to members on coverage and benefits while ensuring compliance with state, federal, and regulatory guidelines for quality and cost-effective member care. We are looking for an experienced RN with background in Inpatient Hospital or Skilled Nursing Facility settings, as well as outpatient coding experience. Knowledge of CPT/HCPCS codes, record review, chart auditing, provider disputes, appeals, and filing 1500 & UB04 claims is highly preferred. This role involves navigating a fast-paced environment with frequent updates to procedures. Essential Job Duties • Conduct clinical and medical reviews of medical claims, including previously denied cases, to confirm medical necessity and accurate billing. • Validate member medical records and ensure correct coding for appropriate reimbursement. • Identify and escalate quality of care issues. • Engage in complex claim reviews, analyzing diagnosis-related groups (DRG), itemized bills, and admission levels. • Manage documents related to claim audits and findings in the database. • Re-evaluate claims and related medical records using advanced clinical knowledge alongside regulatory guidelines. • Collaborate with medical directors on denial decisions using medically accepted guidelines. • Serve as a resource for utilization management and provide training and support for peers. • Assist members with special needs by directing them to the appropriate programs. • Contribute to or lead special project initiatives. Required Qualifications • A minimum of 2 years of clinical nursing experience, ideally in a hospital setting, with at least 1 year in medical claims review or utilization review. • Current, active RN License in state of practice. • Familiarity with state, federal, and third-party regulations. • Strong analytical and problem-solving capabilities. • Excellent organizational and time-management skills. • Detail-oriented with the capability to multitask and adhere to deadlines. • Proficient in Microsoft Office and adaptable to new software. • Outstanding verbal and written communication skills. Preferred Qualifications • Certifications such as Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), or similar. • Experience in critical care, emergency medicine, or pediatrics. • Background in billing and coding. This is a remote position with working hours from Monday to Friday, 8:00 AM to 5:00 PM. Molina Healthcare offers competitive benefits and compensation. We are proud to be an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $26.41 - $61.79 / HOURLY. Actual compensation may vary based on geographic location, work experience, education, and skill level. Apply tot his job Apply To this Job