Remote Medical Review Nurse (RN) - Must Work CST time zone

Job description

Job Description Highlights of the skills and qualifications needed for the Medical Review Nurse: - Registered Nurse with a compact/multi-state license - Must be willing to work a schedule within the Central Time Zone, Monday - Friday - Have at least 2 years of clinical experience as a nurse - Have at least 1 year of experience in the following areas: utilization review, medical claims review, claims auditing, medical necessity review and/or coding experience - Excellent skills working with Microsoft Office Suite - Confidence in having multiple screens open and toggling between them to complete necessary forms and documentation Job Summary: 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. Job Duties: - 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 appropr...