Lead Medical Review Nurse (RN)

Job Summary

Lead Medical Review Nurse (RN), full-time position responsible for overseeing medical claim and internal appeals review activities while ensuring compliance with regulatory requirements and enhancing quality member care.

Key Responsibilities

• Enhance processes related to claims review, training, audits, and production management
• Conduct clinical reviews of medical records and perform audits to ensure payment integrity
• Develop policies and procedures to ensure compliance with coding guidelines and regulatory mandates

Required Qualifications

• At least 4 years of clinical nursing experience and 4 years of claims auditing experience
• Active and unrestricted Registered Nurse (RN) license in the state of practice
• Strong knowledge of coding systems including DRG, ICD-10, CPT, and HCPC
• Extensive background in facility-based nursing or inpatient coding
• Experience with state, federal, and third-party regulations related to healthcare