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 compliance with medical necessity and appropriate care levels, while working remotely to facilitate appeals and validate claims for reimbursement.

Key responsibilities

• Facilitates medical reviews of prior authorization appeals, including inpatient, outpatient, and pharmaceutical cases
• Reevaluates medical claims and associated records to assess service appropriateness and compliance with regulations
• Prepares and presents cases for administrative hearings, supporting recommendations for denial or modification of payment decisions

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 HCPC regulations
• Experience with state and federal healthcare regulations
• Strong analytic and decision-making skills