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Lead, Medical Claim Review Nurse

Molina Healthcare Job ID 2006387
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Job Description
Job Summary
Responsible for administering claims payments, maintaining claim records, and providing counsel to claimants regarding coverage amount and benefit interpretation. Monitors and controls backlog and workflow of claims. Ensures that claims are settled in a timely fashion and in accordance with cost control standards.

• Serves as SME to answer front line questions and provide feedback throughout the day
• Manage daily work assignments
• Monitor staff to meet productivity, quality and established turn around times
• Provide training as assigned by Supervisor
•Collaborate with supervisor on complicated cases; escalate as appropriate
•Evaluate and recommend updates to Job Aids, Resources, and SOP's
•Identify opportunities to increase efficiencies
•Demonstrated ability to work independently and make decisions
•Actively work all applications and review types (working Lead)
Job Qualifications
Required Education
Associate's Degree or equivalent combination of education and experience
Required Experience
Min. 3 years clinical nursing experience, including 1 year Utilization Review and/or Medical Claims Review experience.

2+ years Leadership 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) license in good standing.
Preferred Education
Bachelor's Degree in Nursing or Health Related Field

Coding Certificate (CIC)
Preferred Experience
5+ years Clinical Nursing 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.

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 Time Posting Date: 01/23/2021


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