Illinois and Wisconsin RN Claim Reviewer

Job Summary

A company is looking for a Medical Claim Review Nurse (RN) to perform clinical reviews of medical claims and appeals.

Key Responsibilities

• Conducts clinical reviews of medical claims and appeals to ensure medical necessity and accurate billing
• Identifies quality of care issues and assists with complex claim reviews
• Documents findings and provides clinical support for Utilization Management and appeals processes

Required Qualifications

• Graduate from an Accredited School of Nursing
• Minimum 3 years of clinical nursing experience
• Minimum 1 year of experience in Utilization Review and/or Medical Claims Review
• Active, unrestricted State Registered Nursing (RN) license in good standing
• Familiarity with state/federal regulations