Job Title

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 for denied prior authorizations. Includes standard and expedited cases, inpatient, outpatient, and pharmaceutical authorization appeals. • 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 kn...