Michigan Licensed Medical Review Nurse

Job Summary

Utilizing clinical expertise, the full-time Remote Michigan Licensed Medical Review Nurse will manage the review of medical documentation to ensure medical necessity and compliance with guidelines, while handling appeals for denied prior authorizations and validating claims for appropriate reimbursement.

Key responsibilities

• Facilitates medical review of prospective, retrospective, and concurrent appeals for prior authorizations
• Reevaluates medical claims and associated records to assess appropriateness of services and billing accuracy
• 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
• Experience with ICD-10, CPT coding, and HCPCS
• Knowledge of state, federal, and third-party healthcare regulations
• Strong analytical, problem-solving, and decision-making skills