Medical Review Nurse (RN) - UM/Appeals experience

Job Description Must be available to work day shift hours aligned with Eastern Standard Time (EST) and maintain flexibility to support weekend and holiday coverage as business needs require. Prior experience in Utilization Management (UM) and appeals review, preferably within a Managed Care Organization (MCO) environment, is strongly preferred. Demonstrated knowledge of medical necessity determinations, authorization appeals, regulatory compliance, and healthcare claims review is highly desirable. Job Summary Utilizing clinical knowledge and experience, responsible for review of documentation to ensure medical necessity and appropriate level of care utilizing MCG/InterQual, state/federal guidelines, billing and coding regulations, and Molina policies; validates the medical record and claim submitted support correct coding to ensure appropriate reimbursement to providers. Job Duties • Facilitates medical review of prospective, retrospective, and concurrent review of appeals...