Molina Healthcare RN, Claim Review Non-clinical in Spokane, Washington
Job Summary Responsible for administering claims payments, maintaining claim records, and providing counsel to claimants regarding coverage amount and benefit interpretation. Monitors and controls backlog and workflow of claims. Ensures that claims are settled in a timely fashion and in accordance with cost control standards.
Knowledge/Skills/Abilities • Evaluates medical claims and/or medical records by applying clinical expertise to assess appropriateness of service provided, length of stay and level of care • Identifies and refers all cases not meeting medical necessity criteria and guidelines to the Lead for evaluation • Identifies and reports quality of care issues. • Identifies and refers members with special needs to the appropriate Molina Healthcare program per policy/protocol. • Assists with Complex Claim review; requires decision making pertinent to clinical experience • Documents clinical review summaries, bill audit findings and audit details in the database • Provides supporting documentation for denial and modification of payment decisions
Required Education RN, BSN, or LCSW Bachelor's Degree in Nursing or Health Related Field Required Experience Minimum three years clinical nursing experience. Minimum one year Utilization Review and/or Medical Claims Review. Required License, Certification, Association Active, unrestricted State Registered Nursing (RN) license in good standing. Preferred Education Master's Degree in Nursing or Health Related Field Preferred Experience Nursing experience in Critical Care, Emergency Medicine, Medical Surgical, or Pediatrics. Advanced Practice Nursing. Billing and coding experience. Preferred License, Certification, Association Certified Clinical Coder, Certified Medical Audit Specialists, Certified Case Manager , Certified Professional Healthcare Management, Certified Professional in Healthcare Quality or other healthcare certification.
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Job: *Core Operations
Title: RN, Claim Review Non-clinical
Requisition ID: 1801479