Molina Healthcare

Apply Now

Molina Healthcare
United States
Job ID 2022857


Job Summary

Utilizing clinical knowledge and experience, responsible for review of documentation to ensure medical necessity and appropriate level of care utilizing MCG/InterQual, state/federal guidelines, billing and coding regulations, and Molina policies; validates the medical record and claim submitted support correct coding to ensure appropriate reimbursement to providers.

For this position we are seeking a Medical Claim Review Nurse with previous data analysis and/or project management experience. A background in Utilization Review, Claims Review, Auditing and Medical Necessity Review is beneficial.  Able to work with multiple programs at one time and comfortable learning new healthcare related programs. Further details to be discussed during our interview process.

Remote position

Work hours: Monday through Friday 8:30am – 5:00pm CT

Job Duties

  • 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.
  • Identifies and reports quality of care issues.
  • Assists with Complex Claim review including DRG Validation, Itemized Bill Review, Appropriate Level of Care, Inpatient Readmission, and any opportunity identified by the Payment Integrity analytical team; 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
  • Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care.
  • Reviews medically appropriate clinical guidelines and other appropriate criteria with Medical Directors on denial decisions.
  • Supplies criteria supporting all recommendations for denial or modification of payment decisions.
  • Serves as a clinical resource for Utilization Management, Chief Medical Officers, Physicians, and Member/Provider Inquiries/Appeals.
  • Provides training and support to clinical peers.
  • Identifies and refers members with special needs to the appropriate Molina Healthcare program per policy/protocol.


Graduate from an Accredited School of Nursing


  • Minimum 3 years clinical nursing experience.
  • Minimum one year Utilization Review and/or Medical Claims Review.
  • Minimum two years of experience in Claims Auditing, Medical Necessity Review and Coding experience
  • Familiar with state/federal regulations


Active, unrestricted State Registered Nursing (RN) license in good standing.


Bachelors’s Degree in Nursing or Health Related Field


Nursing experience in Critical Care, Emergency Medicine, Medical Surgical, or Pediatrics. Advanced Practice Nursing.  Billing and coding experience.

Proficiency with Microsoft Word and Excel


Certified Clinical Coder, Certified Medical Audit Specialists, Certified Case Manager , Certified Professional Healthcare Management, Certified Professional in Healthcare Quality or other healthcare certification.

Pay Range:  $23.41 – $51.49 an hour*
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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.

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: 10/16/2023