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Medical Review Nurse (RN)

May 11, 2026

Job Description Job Summary 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 <ul><li>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. </li><li>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.</li><li>Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. </li><li>Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues.</li><li>Identifies and reports quality of care issues.</li><li>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.</li><li>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. </li><li>Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. </li><li>Supplies criteria supporting all recommendations for denial or modification of payment decisions.</li><li>Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. </li><li>Provides training and support to clinical peers. </li><li>Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. </li></ul>Job Qualifications REQUIRED QUALIFICATIONS: <ul><li>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. </li><li>Registered Nurse (RN) in Nevada. License must be active and unrestricted in state of practice. </li><li>Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC).</li><li>Experience working within applicable state, federal, and third-party regulations.</li><li>Analytic, problem-solving, and decision-making skills. </li><li>Organizational and time-management skills.</li><li>Attention to detail.</li><li>Critical-thinking and active listening skills. </li><li>Common look proficiency.</li><li>Effective verbal and written communication skills.</li><li>Microsoft Office suite and applicable software program(s) proficiency. </li></ul>Preferred Qualifications <ul><li>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.</li><li>Utilization Management Experience</li><li>Experience with MCG, PEGA and/or Salesforce </li><li>Billing and coding experience. </li></ul>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: $30.5 - $59.47 / HOURLY <ul><li>Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.</li></ul>

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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

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When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

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Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

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The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

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