Michigan Licensed Medical Review Nurse

Job Summary

Utilizing clinical expertise, the full-time Michigan Licensed Medical Review Nurse will review 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
• Validates medical records and claims to ensure correct coding and appropriate reimbursement to providers
• Prepares and presents cases for administrative hearings and collaborates with medical directors on denial 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 HCPCS
• Experience with state and federal regulations related to healthcare
• Analytical skills and proficiency in Microsoft Office suite