California Licensed Claims Review Nurse

Job Summary

Working remotely, the full-time California Licensed Claims Review Nurse will perform clinical reviews of formal appeals and provider disputes to ensure compliance with organizational policies and state and federal guidelines.

Key responsibilities:

• Reviews claims for medical appropriateness, including provider contract status and benefit interpretation
• Documents denial reasons with appropriate specificity and ensures clarity in communication
• Maintains turnaround time for processing denials and appeals in accordance with federal and state guidelines

Required qualifications:

• Graduation from an accredited school of nursing
• Active, unrestricted RN Nurse license through the State of California
• 1+ year of utilization management or quality improvement experience in a healthcare setting
• Basic Life Support for Healthcare providers certification
• Solid knowledge of Microsoft Office and familiarity with Medicare and health plan guidelines