Florida and Kentucky Licensed Medical Review Nurse

Job Summary

Utilizing clinical expertise, the full-time Florida and Kentucky Licensed Medical Review Nurse will conduct reviews of medical documentation to ensure medical necessity and compliance with guidelines, while working remotely to manage appeals and validate claims for appropriate reimbursement.

Key responsibilities

• Facilitates medical reviews of appeals for prior authorizations and retrospective claims to ensure medical necessity and accurate billing
• Reevaluates medical claims and records, applying clinical knowledge and regulatory requirements to assess service appropriateness
• Serves as a clinical resource for utilization management and provides training and support to clinical peers

Required qualifications

• At least 2 years of clinical nursing experience, including 1 year in utilization review or medical claims review
• Active and unrestricted Registered Nurse (RN) license in Florida or Kentucky; compact license acceptable
• Experience with ICD-10, CPT coding, and HCPCS
• Knowledge of state and federal healthcare regulations
• Analytical skills and proficiency in Microsoft Office and relevant software programs