Molina Healthcare

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Molina Healthcare
Los Angeles, California
Job ID 2022518

Job Description

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.


Remote position. (M-F 8:00 AM to 5:30 PM PST) with flexibility for weekend and Holiday on-call / OT on weekends 

For this position we are seeking a LVN with previous experience with IP/OP Medical Review, MCG criteria and Claims experience  Further details to be discussed during our interview process.


• Responsible for retrospective medical claim reviews of rendered inpatient and outpatient health care services to confirm medical necessity and appropriateness of billing for Molina members.
• Collaborates with the Integrated Healthcare Services team and providers to ensure proper payment for appropriate, high quality, cost effective healthcare services according to State and Federal guidelines and Molina Healthcare Policy.
• Reviews medical claims and records applying Molina Integrated Healthcare Services “decision support tools” and clinical expertise to assess medical appropriateness of services provided, length of stay and level of care.
• Audits claim charges to accurately identify inappropriate and disallowed charges as defined by Centers for Medicare and Medicaid (CMS), Department of Health Services (DHS) and Molina Healthcare billing guidelines.
• Identifies and refers all cases not meeting medical necessity criteria and guidelines to the Medical Director for evaluation.
• Supplies criteria supporting all recommendations for denial or modification of payment decisions.
• Composes and saves member notice(s) for each appeal and for retro authorization requests that are modified or denied per policy/procedure.
• Documents clinical review summaries, bill audit findings and audit details in the database.
• Identifies and reports quality of care issues to the Quality Management Department.
• Reports suspected member or provider fraud per Molina Healthcare Policy.
• Identifies and refers members with special needs to the appropriate Molina Healthcare program per policy/protocol..

Job Qualifications

Required Education
Completion of an accredited Registered Nurse (RN), Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program

Required Experience
Min. 3 years clinical nursing experience, including 1 year Utilization Review and/or Medical Claims Review experience.

Experience demonstrating knowledge of ICD-9, CPT coding and HCPC.

Experience demonstrating knowledge of Medicaid, Medicare, and other insurance plans.

Required License, Certification, Association
Active, unrestricted State Registered Nursing (RN), Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) license in good standing.

Preferred Education
Bachelor’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.

Experience with IP/OP 

Medical Review experience

MCG criteria experience

Claims 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.

Pay Range:  $24.00 – $46.81 an hour*
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

About Us

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Job Type: Full TimePosting Date: 09/12/2023