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
• Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing. • Evaluates medical records and/or medical notes providing clinical expertise on coding accuracy.
• Reviews provider reconsideration requests related to claim edits and validation outcomes.
• Identifies and reports quality of care issues.
• Identifies and refers members with special needs to the appropriate Molina Healthcare program per policy/protocol.
• Helps with the development and implementation of proactive approaches to improve and standardize overall retrospective claims review.
• Ensures core system is updated correctly to process claim..
Job Qualifications
Required Education
Licensed Vocational Nurse / Licensed Practical Nurse.
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 Licensed Vocational Nurse (LVN) license in good standing.
Preferred Education
Registered Nurse.
Bachelor's Degree in Nursing or Health Related Field
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
Registered Nursing license in good standing.
Certified Clinical Coder, Certified Medical Audit Specialists (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ) 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.