Michigan Licensed Medical Review Nurse

Job Summary

Utilizing clinical expertise, the full-time Michigan Licensed Medical Review Nurse will conduct reviews of medical documentation to ensure medical necessity and compliance with guidelines, while working remotely.

Key responsibilities

• Facilitates medical review of appeals for denied prior authorizations, including inpatient and outpatient cases
• Reevaluates medical claims and records to assess appropriateness of services and ensure accurate billing
• 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 Michigan
• Knowledge of ICD-10, CPT coding, and HCPCS
• Experience with state, federal, and third-party healthcare regulations
• Analytic and decision-making skills relevant to clinical assessments