Nurse Coordinator jobs at HCA Healthcare - 71 jobs

For this position we are seeking a (RN) Registered Nurse who must live and have a current active unrestricted RN license in the state of OH Case Manager RN will work in remote and field setting supporting Medicare and Medicaid l health population. This role will be supporting our FIDE-SNP population, completing face to face assessments, care plans, and providing education and support to our members. Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important. Home office with internet connectivity of high speed required. Schedule: Monday thru Friday 8:00AM to 5:00PM Field Travel (Up to 50%) - Union, Delaware, Franklin, Madison, and Pickaway (Columbus OH). (Mileage is reimbursed) JOB DESCRIPTION Job Summary Provides support for care management/care coordination activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Completes comprehensive assessments of members per regulated timelines and determines who may qualify for care management based on clinical judgment, changes in member health or psychosocial wellness and triggers identified in assessments. • Develops and implements care coordination plan in collaboration with member, caregiver, physician and/or other appropriate health care professionals and member support network to address member needs and goals. • Conducts telephonic, face-to-face or home visits as required. • Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. • Maintains ongoing member caseload for regular outreach and management. • Promotes integration of services for members including behavioral health, long-term services and supports (LTSS), and home and community resources to enhance continuity of care. • Facilitates interdisciplinary care team (ICT) meetings and informal ICT collaboration. • Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. • Assesses for barriers to care, provides care coordination and assistance to member to address concerns. • May provide consultation, resources and recommendations to peers as needed. • Care manager RNs may be assigned complex member cases and medication regimens. • Care manager RNs may conduct medication reconciliation as needed. • 25-40% estimated local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 2 years experience in health care, preferably in care management, or experience in a medical and/or behavioral health setting, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. • Understanding of the electronic medical record (EMR) and Health Insurance Portability and Accountability Act (HIPAA). • Demonstrated knowledge of community resources. • Ability to operate proactively and demonstrate detail-oriented work. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations. • Ability to work independently, with minimal supervision and self-motivation. • Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations. • Ability to develop and maintain professional relationships. • Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. • Excellent problem-solving, and critical-thinking skills. • Strong verbal and written communication skills. • Microsoft Office suite/applicable software program proficiency, and ability to navigate online portals and databases. Preferred Qualifications • Certified Case Manager (CCM). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. Job Duties * Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. * Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. * Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. * Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. * Identifies and reports quality of care issues. * Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. * Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. * 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, CMOs, physicians and member/provider inquiries/appeals. * Provides training and support to clinical peers. * Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: * At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. * Registered Nurse (RN). License must be active and unrestricted in state of practice. * Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). * Experience working within applicable state, federal, and third-party regulations. * Analytic, problem-solving, and decision-making skills. * Organizational and time-management skills. * Attention to detail. * Critical-thinking and active listening skills. * Common look proficiency. * Effective verbal and written communication skills. * Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: * Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. * Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. * Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $67.97 / HOURLY * 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.

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. ESSENTIAL JOB DUTIES: Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. 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, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. ESSENTIAL JOB DUTIES: Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. 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, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

The USPI Utilization Review/Appeals RN is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient's resources and right to self-determination across United Surgical Partners International (USPI) Hospitals. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. This position manages medical necessity process for accurate and timely payment for services which may require negotiation with a payer on a case-by-case basis. This position integrates national standards for case management scope of services including: Utilization Management services supporting medical necessity and denial prevention Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient Compliance with state and federal regulatory requirements, TJC accreditation standards and USPI policy Education provided to payers, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review Preparing and documenting appeal letters based on industry accepted criteria. REQUIREMENTS Required: 5 years of acute hospital or behavioral health patient care experience with at least 2 years utilization review in an acute hospital, surgical hospital, or commercial/managed care payer setting. Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy. Active RN license for state(s) covered. Experience in writing appeals. Preferred: Accredited Case Manager (ACM). Previous classroom led instruction on InterQual products (Acute Adult, Peds, Outpatient and Procedures). Patient Accounting experience a plus. Managed care payor experience a plus either in Utilization Review, Case Management or Appeals. Interaction with facility Case Management, Physician Advisor, and Revenue Cycle Team is a requirement. May require travel up to 25% travel across USPI hospitals. The selected candidate will be required to pass a Motor Vehicle Records check. Compensation Pay: $70,096-$112,112 annually. Compensation depends on location, qualifications, and experience. Management level positions may be eligible for sign-on and relocation bonuses. Benefits The following benefits are available, subject to employment status: Medical, dental, vision, disability, life, AD&D, and business travel insurance Paid time off (vacation & sick leave) Discretionary 401k match 10 paid holidays per year Health savings accounts, healthcare & dependent flexible spending accounts Employee Assistance program, Employee discount program Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance. For Colorado employees, paid leave in accordance with Colorado's Healthy Families and Workplaces Act is available. RESPONSIBILITIES Clinical Denials/Appeals Performs retrospective (post -discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review. Constructs and documents a succinct and fact-based clinical case to support appeal utilizing appropriate module of InterQual criteria (Acute, Procedures, etc.). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization. Demonstrates ability to critically think, problem solve and make independent decisions supporting the clinical appellate process. Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual , as evidenced by Inter-rater reliability studies and other QA audits. Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, etc. Utilization Management Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes Completes and sends admission and concurrent reviews for payers with an authorization process identifies and documents Avoidable Days using the data to address opportunities for improvement Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay and discharge) compared to evidence-based practice, internal and external requirements. Payer Authorization Assures the patient is in the appropriate status and level of care based on Medical Necessity and submits case for Secondary Physician review per USPI policy Ensures timely communication and documentation of clinical data to payers to support admission, level of care, length of stay and authorization Advocates for the patient and hospital with payers to secure appropriate payment for services rendered Prevents denials and disputes by communicating with payers and documenting relevant information Manages payer dispute processes utilizing secondary review, peer to peer and payer type changes Education Ensures and provides education to physicians and the healthcare team relevant to the: Effective progression of care, Appropriate level of care, and Safe and timely patient transition Provides healthcare team education regarding resources and benefits available to the patient along with the economic impact of care options Compliance Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and USPI policies Operates within the RN scope of practice as defined by state licensing regulations Remains current with USPI Case Management practices Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Ability to lift 15-20lbs Ability to travel approximately 25% of the time; either to facility sites, headquarters or other designated sites Ability to sit and work at a computer for a prolonged period conducting medical necessity reviews and appeal letters

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. Job Duties * Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. * Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. * Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. * Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. * Identifies and reports quality of care issues. * Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. * Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. * 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, CMOs, physicians and member/provider inquiries/appeals. * Provides training and support to clinical peers. * Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: * At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. * Registered Nurse (RN). License must be active and unrestricted in state of practice. * Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). * Experience working within applicable state, federal, and third-party regulations. * Analytic, problem-solving, and decision-making skills. * Organizational and time-management skills. * Attention to detail. * Critical-thinking and active listening skills. * Common look proficiency. * Effective verbal and written communication skills. * Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: * Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. * Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. * Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $67.97 / HOURLY * 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.

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. **Job Duties** + Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. + Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. + Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. + Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. + Identifies and reports quality of care issues. + Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. + Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. + 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, CMOs, physicians and member/provider inquiries/appeals. + Provides training and support to clinical peers. + Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. **Job Qualifications** **REQUIRED QUALIFICATIONS:** + At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. + Registered Nurse (RN). License must be active and unrestricted in state of practice. + Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). + Experience working within applicable state, federal, and third-party regulations. + Analytic, problem-solving, and decision-making skills. + Organizational and time-management skills. + Attention to detail. + Critical-thinking and active listening skills. + Common look proficiency. + Effective verbal and written communication skills. + Microsoft Office suite and applicable software program(s) proficiency. **PREFERRED QUALIFICATIONS:** + Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. + Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. + Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides screening, preventive primary care and medical care services to members - primarily in non-clinical settings where members feel most comfortable, including in-home, community and nursing facilities and “pop up” clinics. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Provides general medical care and care coordination to various and/or specific patient member populations - adult, women's health, pediatric, and geriatric. • Performs comprehensive evaluations including history and physical exams for gaps in care and preventive assessments. • Addresses both chronic and acute primary care complaints, and demonstrates ability to ascertain medical urgency. • Establishes and documents reasonable medical diagnoses. • Seeks specialty consultation as appropriate. • Orders/performs pertinent diagnostic laboratory and radiology testing for the medical diagnosis or presenting symptoms; works within an environment of limited resources and therefore uses diagnostic tests judiciously and appropriately. • Understands when a member's needs are beyond their scope of knowledge and when physician oversight is needed. • Creates and implements a medical plan of care. • Schedules appointments for visits when appropriate. • Provides post-discharge coordination to reduce hospital readmission rates and emergency room utilization. • Performs face-to-face in-person visits in a variety of settings including in-home, skilled nursing facilities, and public locations. • Performs face-to-face visits via alternative modalities based on business need, leadership direction and state regulations. • Orders bulk laboratory orders to target specific member populations. • Performs alternating on-call coverage to triage any urgent lab results and pharmacy inquiries and develops appropriate plans of care. • Participates in community-based “pop up clinics” to build relationships with communities, and address gaps in health care. • Drives up to 120 miles a day on a regular basis to a variety of locations within the assigned region. Drives beyond 120 miles as part of extended mileage may be required on special project days. Special projects may include an overnight hotel stay. • Obtains and maintains cross-state license in other states besides home state based on business need. • Collaborates with fellow nurse practitioners to develop best practices to perform work duties efficiently and effectively. • Actively participates in regional meetings. • May prescribe medications and perform procedures as appropriate. • Performs timely medical records documentation in electronic medical record (EMR) computer system. • On occasion, may be required to walk flights of stairs while carrying up to 50 lbs. of equipment. • Engages in practices constituting the practice of medicine in collaboration with and under the medical direction and supervision of a licensed physician to the degree required by state laws. • Local travel required (based upon state/contractual requirements). Required Qualifications • At least 1 year of experience as a nurse practitioner, or equivalent combination of relevant education and experience. • Active and unrestricted national certification from one of the following organizations: American Academy of Nurse Practitioners (AANP) or American Nurses Credentialing Center (ANCC). • Current state-issued license to practice as a Family Nurse Practitioner (FNP). License must be active and unrestricted in state of practice. • Prescriber Drug Enforcement Agency (DEA) license with authority to prescribe per state qualifications. License must be active and unrestricted in state of practice. • Current Basic Life Support (BLS) certification. • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations. • Ability to work independently with minimal supervision and demonstrate self-motivation. • Responsive in all forms of communication. • Ability to remain calm in high-pressure situations. • Ability to develop and maintain professional relationships. • Excellent time-management and prioritization skills; ability to focus on multiple projects simultaneously and adapt to change. • Excellent problem-solving and critical-thinking skills. • Strong verbal and written communication skills. • Microsoft Office suite/applicable software program(s) proficiency, and electronic medical record (EMR) experience. Preferred Qualifications • Experience as a registered nurse or nurse practitioner in a home health, community health or public health setting. • Experience in home health as a licensed clinician, especially in management of chronic conditions. • Experience with underserved populations facing socioeconomic barriers to health care. • Immunization and point of care testing skills. • Bilingual. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V #PJNurse #LI-AC1 Pay Range: $88,453 - $172,484 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. **Job Duties** + Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. + Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. + Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. + Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. + Identifies and reports quality of care issues. + Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. + Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. + 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, CMOs, physicians and member/provider inquiries/appeals. + Provides training and support to clinical peers. + Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. **Job Qualifications** **REQUIRED QUALIFICATIONS:** + At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. + Registered Nurse (RN). License must be active and unrestricted in state of practice. + Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). + Experience working within applicable state, federal, and third-party regulations. + Analytic, problem-solving, and decision-making skills. + Organizational and time-management skills. + Attention to detail. + Critical-thinking and active listening skills. + Common look proficiency. + Effective verbal and written communication skills. + Microsoft Office suite and applicable software program(s) proficiency. **PREFERRED QUALIFICATIONS:** + Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. + Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. + Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. **ESSENTIAL JOB DUTIES:** + Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. + Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. + Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. + Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. + Identifies and reports quality of care issues. + Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. + Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. + 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, CMOs, physicians and member/provider inquiries/appeals. + Provides training and support to clinical peers. + Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. **REQUIRED QUALIFICATIONS:** + At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. + Registered Nurse (RN). License must be active and unrestricted in state of practice. + Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). + Experience working within applicable state, federal, and third-party regulations. + Analytic, problem-solving, and decision-making skills. + Organizational and time-management skills. + Attention to detail. + Critical-thinking and active listening skills. + Common look proficiency. + Effective verbal and written communication skills. + Microsoft Office suite and applicable software program(s) proficiency. **PREFERRED QUALIFICATIONS:** + Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. + Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. + Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. Job Duties * Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. * Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. * Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. * Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. * Identifies and reports quality of care issues. * Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. * Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. * 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, CMOs, physicians and member/provider inquiries/appeals. * Provides training and support to clinical peers. * Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: * At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. * Registered Nurse (RN). License must be active and unrestricted in state of practice. * Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). * Experience working within applicable state, federal, and third-party regulations. * Analytic, problem-solving, and decision-making skills. * Organizational and time-management skills. * Attention to detail. * Critical-thinking and active listening skills. * Common look proficiency. * Effective verbal and written communication skills. * Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: * Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. * Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. * Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $67.97 / HOURLY * 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.

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. **Job Duties** + Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. + Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. + Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. + Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. + Identifies and reports quality of care issues. + Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. + Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. + 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, CMOs, physicians and member/provider inquiries/appeals. + Provides training and support to clinical peers. + Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. **Job Qualifications** **REQUIRED QUALIFICATIONS:** + At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. + Registered Nurse (RN). License must be active and unrestricted in state of practice. + Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). + Experience working within applicable state, federal, and third-party regulations. + Analytic, problem-solving, and decision-making skills. + Organizational and time-management skills. + Attention to detail. + Critical-thinking and active listening skills. + Common look proficiency. + Effective verbal and written communication skills. + Microsoft Office suite and applicable software program(s) proficiency. **PREFERRED QUALIFICATIONS:** + Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. + Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. + Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. **ESSENTIAL JOB DUTIES:** + Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. + Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. + Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. + Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. + Identifies and reports quality of care issues. + Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. + Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. + 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, CMOs, physicians and member/provider inquiries/appeals. + Provides training and support to clinical peers. + Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. **REQUIRED QUALIFICATIONS:** + At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. + Registered Nurse (RN). License must be active and unrestricted in state of practice. + Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). + Experience working within applicable state, federal, and third-party regulations. + Analytic, problem-solving, and decision-making skills. + Organizational and time-management skills. + Attention to detail. + Critical-thinking and active listening skills. + Common look proficiency. + Effective verbal and written communication skills. + Microsoft Office suite and applicable software program(s) proficiency. **PREFERRED QUALIFICATIONS:** + Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. + Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. + Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. Job Duties * Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. * Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. * Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. * Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. * Identifies and reports quality of care issues. * Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. * Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. * 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, CMOs, physicians and member/provider inquiries/appeals. * Provides training and support to clinical peers. * Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: * At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. * Registered Nurse (RN). License must be active and unrestricted in state of practice. * Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). * Experience working within applicable state, federal, and third-party regulations. * Analytic, problem-solving, and decision-making skills. * Organizational and time-management skills. * Attention to detail. * Critical-thinking and active listening skills. * Common look proficiency. * Effective verbal and written communication skills. * Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: * Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. * Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. * Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $67.97 / HOURLY * 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.

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. ESSENTIAL JOB DUTIES: * Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. * Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. * Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. * Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. * Identifies and reports quality of care issues. * Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. * Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. * 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, CMOs, physicians and member/provider inquiries/appeals. * Provides training and support to clinical peers. * Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. REQUIRED QUALIFICATIONS: * At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. * Registered Nurse (RN). License must be active and unrestricted in state of practice. * Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). * Experience working within applicable state, federal, and third-party regulations. * Analytic, problem-solving, and decision-making skills. * Organizational and time-management skills. * Attention to detail. * Critical-thinking and active listening skills. * Common look proficiency. * Effective verbal and written communication skills. * Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: * Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. * Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. * Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $29.05 - $67.97 / HOURLY * 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.

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. Job Duties * Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. * Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. * Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. * Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. * Identifies and reports quality of care issues. * Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. * Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. * 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, CMOs, physicians and member/provider inquiries/appeals. * Provides training and support to clinical peers. * Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: * At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. * Registered Nurse (RN). License must be active and unrestricted in state of practice. * Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). * Experience working within applicable state, federal, and third-party regulations. * Analytic, problem-solving, and decision-making skills. * Organizational and time-management skills. * Attention to detail. * Critical-thinking and active listening skills. * Common look proficiency. * Effective verbal and written communication skills. * Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: * Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. * Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. * Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $67.97 / HOURLY * 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.

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. **ESSENTIAL JOB DUTIES:** + Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. + Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. + Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. + Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. + Identifies and reports quality of care issues. + Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. + Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. + 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, CMOs, physicians and member/provider inquiries/appeals. + Provides training and support to clinical peers. + Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. **REQUIRED QUALIFICATIONS:** + At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. + Registered Nurse (RN). License must be active and unrestricted in state of practice. + Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). + Experience working within applicable state, federal, and third-party regulations. + Analytic, problem-solving, and decision-making skills. + Organizational and time-management skills. + Attention to detail. + Critical-thinking and active listening skills. + Common look proficiency. + Effective verbal and written communication skills. + Microsoft Office suite and applicable software program(s) proficiency. **PREFERRED QUALIFICATIONS:** + Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. + Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. + Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. **Job Duties** + Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. + Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. + Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. + Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. + Identifies and reports quality of care issues. + Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. + Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. + 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, CMOs, physicians and member/provider inquiries/appeals. + Provides training and support to clinical peers. + Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. **Job Qualifications** **REQUIRED QUALIFICATIONS:** + At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. + Registered Nurse (RN). License must be active and unrestricted in state of practice. + Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). + Experience working within applicable state, federal, and third-party regulations. + Analytic, problem-solving, and decision-making skills. + Organizational and time-management skills. + Attention to detail. + Critical-thinking and active listening skills. + Common look proficiency. + Effective verbal and written communication skills. + Microsoft Office suite and applicable software program(s) proficiency. **PREFERRED QUALIFICATIONS:** + Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. + Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. + Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

For this position we are seeking a (RN) Registered Nurse who must live and have a current active unrestricted RN license in the state of OH Case Manager RN will work in remote and field setting supporting Medicare and Medicaid l health population. This role will be supporting our FIDE-SNP population, completing face to face assessments, care plans, and providing education and support to our members. Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important. Home office with internet connectivity of high speed required. Schedule: Monday thru Friday 8:00AM to 5:00PM Field Travel (Up to 50%) - Union, Delaware, Franklin, Madison, and Pickaway (Columbus OH). (Mileage is reimbursed) JOB DESCRIPTION Job Summary Provides support for care management/care coordination activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Completes comprehensive assessments of members per regulated timelines and determines who may qualify for care management based on clinical judgment, changes in member health or psychosocial wellness and triggers identified in assessments. • Develops and implements care coordination plan in collaboration with member, caregiver, physician and/or other appropriate health care professionals and member support network to address member needs and goals. • Conducts telephonic, face-to-face or home visits as required. • Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. • Maintains ongoing member caseload for regular outreach and management. • Promotes integration of services for members including behavioral health, long-term services and supports (LTSS), and home and community resources to enhance continuity of care. • Facilitates interdisciplinary care team (ICT) meetings and informal ICT collaboration. • Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. • Assesses for barriers to care, provides care coordination and assistance to member to address concerns. • May provide consultation, resources and recommendations to peers as needed. • Care manager RNs may be assigned complex member cases and medication regimens. • Care manager RNs may conduct medication reconciliation as needed. • 25-40% estimated local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 2 years experience in health care, preferably in care management, or experience in a medical and/or behavioral health setting, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. • Understanding of the electronic medical record (EMR) and Health Insurance Portability and Accountability Act (HIPAA). • Demonstrated knowledge of community resources. • Ability to operate proactively and demonstrate detail-oriented work. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations. • Ability to work independently, with minimal supervision and self-motivation. • Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations. • Ability to develop and maintain professional relationships. • Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. • Excellent problem-solving, and critical-thinking skills. • Strong verbal and written communication skills. • Microsoft Office suite/applicable software program proficiency, and ability to navigate online portals and databases. Preferred Qualifications • Certified Case Manager (CCM). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.