Home › Companies › Hckd Fa Us2 Oraclecloud Com CX 1 › Medical Review Nurse -UM/Post Appeals (Michigan RN license req)
Medical Review Nurse -UM/Post Appeals (Michigan RN license req)
Hckd Fa Us2 Oraclecloud Com CX 1 · MI, United States; Remote Employees, Long Beach, CA, US · Remote · Active · Oracle Recruiting Cloud / Fusion HCM
Job facts
| Field | Value |
|---|---|
| Company | Hckd Fa Us2 Oraclecloud Com CX 1 |
| Title | Medical Review Nurse -UM/Post Appeals (Michigan RN license req) |
| Normalized title | - |
| Department / team | Clinical |
| Location | MI, United States |
| Work model | Remote / Remote |
| Employment type | Full Time |
| Salary | - |
| Status | active |
| ATS provider | Oracle Recruiting Cloud / Fusion HCM |
| Posted / first seen | 2026-05-18 / 2026-05-31 |
| Changed / last seen | 2026-06-02 / 2026-06-06 |
Related slices
| Page | What it contains | Open |
|---|---|---|
| Company jobs | Active postings from Hckd Fa Us2 Oraclecloud Com CX 1. | Open |
| Company breakdowns | Role, location, ATS, and work model facets for this company. | Open |
| ATS provider jobs | Active postings observed through Oracle Recruiting Cloud / Fusion HCM. | Open |
| Provider filtered search | The same provider as a filtered job collection. | Open |
| Department jobs | Active postings in Clinical. | Open |
| Work model jobs | Active Remote postings. | Open |
| Lifecycle events | Open, update, close, and reopen events for this posting. | Open |
| Original posting | Canonical source or apply URL captured from the ATS. | Open |
Linked records
| Company | Hckd Fa Us2 Oraclecloud Com CX 1 |
| Source | 8214b818-efda-4f30-9713-cac0e888e0f9 |
| ATS provider | Oracle Recruiting Cloud / Fusion HCM |
Description
Description
Job Description
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 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.
Job Qualifications
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.
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.
Full job record
| Job ID | 2797c095e62a47c85b09bd936a2b513ffcd11fa9 |
| Org ID | 6fcfe228-ec8c-4e31-bf8d-2e5d2cb49f0a |
| Source ID | 8214b818-efda-4f30-9713-cac0e888e0f9 |
| Board ID | 8214b818-efda-4f30-9713-cac0e888e0f9 |
| Provider | oracle_hcm |
| Provider Job Key | 2037535 |
| Title | Medical Review Nurse -UM/Post Appeals (Michigan RN license req) |
| Normalized Title | — |
| Status | active |
| Active | yes |
| Location Text | MI, United States; Remote Employees, Long Beach, CA, US |
| Department | Clinical |
| Team | — |
| Employment Type | full_time |
| Workplace Type | remote |
| Remote Policy | remote |
| Country | United States |
| Region | MI |
| City | — |
| Salary Raw | Description Job Description 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 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. Job Qualifications 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. 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. |
| Salary Min | — |
| Salary Max | — |
| Salary Currency | — |
| Salary Period | — |
| Source URL | https://hckd.fa.us2.oraclecloud.com/hcmUI/CandidateExperience/en/sites/CX_1/job/2037535 |
| Apply URL | https://hckd.fa.us2.oraclecloud.com/hcmUI/CandidateExperience/en/sites/CX_1/job/2037535 |
| First Seen At | 2026-05-31 18:03:56Z |
| Last Seen At | 2026-06-06 11:30:43Z |
| Last Checked At | 2026-06-06 11:30:43Z |
| Last Changed At | 2026-06-02 11:30:26Z |
| Inactive At | — |
| Source Posted At | 2026-05-18 17:19:51Z |
| Source Updated At | — |
| Raw Payload Uri | s3://job-postings-prod-raw-590183727216/raw/provider=oracle_hcm/board=hckd.fa.us2.oraclecloud.com|CX_1/date=2026-06-06/2026-06-06T11-30-00-878Z-5a444c553533de92339bc7e174bf6b5a8b1de72b0bf53453749588ed04e6f9bf.json |
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"Latitude": 43.05042,
"Longitude": -76.14738,
"CountryCode": "US",
"GeographyId": 300000001285288,
"GeographyNodeId": 100009205132578,
"RequisitionLocationId": 300002898512779
},
{
"Name": "Columbus, OH, United States",
"Latitude": 40.13728,
"Longitude": -82.98654,
"CountryCode": "US",
"GeographyId": 300000001288201,
"GeographyNodeId": 100009205135336,
"RequisitionLocationId": 300002898512408
}
],
"ShortDescriptionStr": "",
"requisitionFlexFields": [],
"DomesticTravelRequired": null,
"PrimaryLocationCountry": "US",
"ExternalQualificationsStr": null,
"ExternalResponsibilitiesStr": null,
"InternationalTravelRequired": null
},
"detail_meta": {
"url": "https://hckd.fa.us2.oraclecloud.com/hcmRestApi/resources/latest/recruitingCEJobRequisitionDetails?expand=all&onlyData=true&finder=ById;Id=%222037535%22,siteNumber=CX_1",
"http_status": 200,
"content_type": "application/json",
"response_bytes": 37860
},
"detail_errors": []
}Get this page with API
Rendered from the bluedoor Job Postings API. Reproduce it:
GET https://api.bluedoor.sh/job-postings/v1/jobs/2797c095e62a47c85b09bd936a2b513ffcd11fa9?include=descriptionJSONGET https://api.bluedoor.sh/job-postings/v1/orgs/6fcfe228-ec8c-4e31-bf8d-2e5d2cb49f0aJSONGET https://api.bluedoor.sh/job-postings/v1/sources/8214b818-efda-4f30-9713-cac0e888e0f9JSONGET https://api.bluedoor.sh/job-postings/v1/jobs/2797c095e62a47c85b09bd936a2b513ffcd11fa9/eventsJSON