California Licensed Medical Claim Nurse

Job Summary

A company is looking for a Medical Claim Review Nurse to perform clinical reviews of medical claims and ensure compliance with regulations.

Key Responsibilities

• Conduct clinical/medical reviews of medical claims and previously denied cases to ensure medical necessity and accurate billing
• Document clinical review summaries and provide supporting documentation for payment decision modifications
• Serve as a clinical resource and provide training to peers while identifying members with special needs for appropriate referrals

Required Qualifications

• Graduate from an Accredited School of Nursing
• Minimum 3 years of clinical nursing experience
• At least 1 year of experience in Utilization Review and/or Medical Claims Review
• Minimum 2 years of experience in Claims Auditing, Medical Necessity Review, and Coding
• Active, unrestricted State Registered Nursing (RN) license in good standing