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Senior Rn Utilization Review Nurse Jobs Near Me

Humana

Utilization Management RN

Columbus, OH · On-site

Become a part of our caring community The Utilization Management Nurse, National Medicaid Clinical ... The RN Review Nurse works closely with healthcare providers, interdisciplinary teams, and non ...

Integrated Resources INC

Care Review Nurse

Columbus, OH · On-site

Works with the Utilization Management team primarily responsible for inpatient medical necessity ... Review cases for in patients/in hospital: skilled care, acute rehab and long term acute care Nurses ...

Molina Healthcare

Medical Review Nurse (RN)

Columbus, OH · On-site

$29.05 - $56.64/hr

... utilization management and long-term services and supports (LTSS) issues. • Identifies and ... complex claim review including diagnosis-related group (DRG) validation, itemized bill review ...

New

AndHealth

Senior Registered Nurse (RN)

Columbus, OH · On-site

Senior Registered Nurse (RN) Full Time Columbus, Ohio AndHealth is on a mission to radically ... Receive, and route test results for provider review, and collect data regarding patient medications.

AndHealth

Senior Registered Nurse (RN)

Columbus, OH · On-site

Senior Registered Nurse (RN) Full Time Columbus, Ohio AndHealth is on a mission to radically ... Receive, and route test results for provider review, and collect data regarding patient medications.

AndHealth

Senior Registered Nurse (RN)

Columbus, OH · On-site

$90K/yr

Senior Registered Nurse (RN) Full Time Columbus, Ohio AndHealth is on a mission to radically ... Receive, and route test results for provider review, and collect data regarding patient medications.

Integrated Resources INC

License Practical Nurse

Columbus, OH · On-site

$24.75 - $33.75/hr

... utilization review and other utilization management activities aimed at providing Healthcare ... Completion of an accredited Registered Nursing program. (a combination of experience and education ...

TEEMA Group

Registered Nurse - RN

Columbus, OH · On-site

$85K - $95K/yr

The Registered Nurse (RN) Care Manager plays a vital role in providing exceptional, patient ... Participate actively in team meetings, quality improvement projects, and utilization review ...

TEEMA Group

Registered Nurse - RN

Columbus, OH · On-site

$85K - $95K/yr

The Registered Nurse (RN) Care Manager plays a vital role in providing exceptional, patient ... Participate actively in team meetings, quality improvement projects, and utilization review ...

TEEMA Group

Registered Nurse - RN

Columbus, OH · On-site

$85K - $95K/yr

The Registered Nurse (RN) Care Manager plays a vital role in providing exceptional, patient ... Participate actively in team meetings, quality improvement projects, and utilization review ...

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How much do senior rn utilization review nurse jobs pay per hour?

As of Aug 9, 2026, the average hourly pay for senior rn utilization review nurse in the United States is $42.28, according to ZipRecruiter salary data. Most workers in this role earn between $33.41 and $48.56 per hour, depending on experience, location, and employer.
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Senior Rn Utilization Review Nurse jobs near you
A map of the United States highlighting the number of Senior Rn Utilization Review Nurse job openings by state according to ZipRecruiter. The image is accompanied by a detailed chart listing the number of Senior Rn Utilization Review Nurse job openings in each state, with California having the most at 2 and Hawaii the least at 0.

Medical Review Nurse (RN)

Molina Healthcare

Columbus, OH • On-site

Other

Posted 2 days ago

New

Molina Healthcare rating

8.0

Company rating: 8.0 out of 10

Based on 198 frontline employees who took The Breakroom Quiz

163rd of 304 rated insurance

Job description

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 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 (prospective, retrospective and concurrent clinical 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. Compact license is acceptable where states allow.

• 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.

What Molina Healthcare employees say

Pay

Benefits

Hours and flexibility

Workplace

Get the full story on Breakroom

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About Molina Healthcare

Sourced by ZipRecruiter

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.

Industry

Health care and social assistance

Company size

10,000+ Employees

Headquarters location

Long Beach, CA, US

Year founded

1980

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