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 Now
Apply Now
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 Now
Apply Now