California Licensed Claims Review Nurse

Job Summary

Working remotely, the full-time California Licensed Claims Review Nurse will conduct timely medical reviews of facility and professional claims and appeals, identify process improvements, and support clinical determinations in alignment with the Supervisor, Integrated Transitional Care.

Key responsibilities

• Conduct timely medical reviews of claims and appeals
• Identify and recommend process improvements between Claims and Utilization Management teams
• Exercise independent judgment in clinical determinations and claims reviews

Required qualifications

• Active, unrestricted Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians
• High school diploma or GED; Associate's degree in health care or related field preferred
• Minimum of one year of relevant work experience in inpatient and outpatient utilization and case management
• Experience in auditing claims and reviewing inpatient medical records preferred
• Knowledge of CPT, ICD-10, HCPCS, and hospital revenue codes