Michigan Licensed Medical Review Nurse

Job Summary

Utilizing clinical expertise, the full-time Michigan Licensed Medical Review Nurse will manage the review of documentation to ensure medical necessity and appropriate levels of care, while validating medical records and claims for accurate reimbursement, all in a remote capacity.

Key responsibilities:

• Facilitates medical reviews of appeals for denied prior authorizations, including inpatient and outpatient cases
• Reevaluates medical claims and records to assess service appropriateness, length of stay, and readmissions
• 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 with 1 year in utilization review or medical claims review
• Active and unrestricted Registered Nurse (RN) license in Michigan
• Knowledge of ICD-10, CPT coding, and HCPC regulations
• Experience with state and federal healthcare regulations
• Analytic and decision-making skills relevant to clinical assessments