Role Description 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 to support correct coding to ensure appropriate reimbursement to providers. - Facilitates medical review of prospective, retrospective, and concurrent review of appeals for denied prior authorizations, including 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. 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. Requirements - 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. Benefits Molina Healthcare offers a competitive benefits and compensation package.

• Develop and execute the territory KOL/HCP engagement plan, including identification, mapping, and prioritization of thought leaders, prescribers and treatment centers. • Deliver scientific presentations and engage in scientific exchange with KOLs and HCPs on Deramiocel clinical data, the DMD cardiomyopathy landscape, and emerging evidence. • Support advisory boards, scientific symposia, and KOL-led research initiatives. • Identify and support investigator-initiated studies (IIS) and real-world evidence opportunities in coordination with HEOR / RWE and Medical Director. • Provide scientific support for medical congresses, including DMD, neuromuscular, cardiology, and rare-disease forums. • Collect and synthesize field insights on clinical practice, treatment decision-making, and emerging evidence; translate insights into recommendations for medical strategy. • Provide scientific training and support to internal stakeholders (Sales, Market Access, Patient Services) in compliance with channel and engagement rules. • Maintain comprehensive scientific fluency on Deramiocel clinical data, DMD natural history, and the broader treatment landscape. • Ensure timely reporting of adverse events and product complaints in line with company and regulatory processes. • Document field activities, KOL/HCP engagement, and insights in Capricor's medical CRM in compliance with standards. • Ensure all activities follow FDA, OIG, PhRMA Code, ACCME, and Capricor compliance standards.

• Develop and execute the territory KOL/HCP engagement plan, including identification, mapping, and prioritization of thought leaders, prescribers and treatment centers. • Deliver scientific presentations and engage in scientific exchange with KOLs and HCPs on Deramiocel clinical data, the DMD cardiomyopathy landscape, and emerging evidence. • Support advisory boards, scientific symposia, and KOL-led research initiatives. • Identify and support investigator-initiated studies (IIS) and real-world evidence opportunities in coordination with HEOR / RWE and Medical Director. • Provide scientific support for medical congresses, including DMD, neuromuscular, cardiology, and rare-disease forums. • Collect and synthesize field insights on clinical practice, treatment decision-making, and emerging evidence; translate insights into recommendations for medical strategy. • Provide scientific training and support to internal stakeholders (Sales, Market Access, Patient Services) in compliance with channel and engagement rules. • Maintain comprehensive scientific fluency on Deramiocel clinical data, DMD natural history, and the broader treatment landscape. • Ensure timely reporting of adverse events and product complaints in line with company and regulatory processes. • Document field activities, KOL/HCP engagement, and insights in Capricor's medical CRM in compliance with standards. • Ensure all activities follow FDA, OIG, PhRMA Code, ACCME, and Capricor compliance standards. • Perform other duties as may be assigned from time to time.

• Provide strategic leadership, vision, and support to the project teams, ensuring alignment with the company's goals and client expectations. • Drive PM performance, project quality delivery, milestone timeline adherence, financial margin optimization, and customer satisfaction through efficient and effective directorship. • Ensure project teams prepare project plans to meet contracted services and timelines. • Lead and mentor multidisciplinary project teams, including Project Managers, Operations teams, vendors, and other functional staff, ensuring effective communication, collaboration, and performance of project deliverables according to contract terms. • Select, contract, and manage external vendors and subcontractors, when necessary, while maintaining quality and cost-effectiveness. • Monitor delivery of projects per scope and budgets, and demonstrate strong oversight of financial health for assigned projects. • Proactive, ongoing identification of project risks and development of mitigating strategies to minimize their impact on projects effectively. • Serve as the UBC senior operational contact with clients for all project related items, maintaining strong relationships, addressing their needs, and providing regular project updates. • Implement quality control measures to maintain the highest standards of data integrity, patient safety, and protocol compliance. • Prepare, maintain, and deliver high quality project progress reports, metrics, and other outputs to clients and UBC senior management. • Assist, as directed, on specific business development opportunities: capabilities presentations, RFP review, proposals/budget input, bid defence participation. • Lead, innovate, and develop operational strategies that meet requirements and maximize project delivery success. • Identify and develop UBC process improvements. • Manage the process of identifying/tracking staffing requirements and liaise with Human Resources regarding strategy, hiring, and onboarding project management resources.