Michigan Licensed Medical Review Nurse

Job Summary

Utilizing clinical expertise, the full-time Michigan Licensed Medical Review Nurse will conduct reviews of medical documentation for necessity and appropriate care levels, ensuring compliance with guidelines and regulations while working remotely.

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 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
• Knowledge of ICD-10, CPT coding, and HCPCS
• Experience with state and federal regulations related to healthcare
• Strong analytical and decision-making skills