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 appropriate levels of care, focusing on appeals for denied prior authorizations in a remote setting.

Key responsibilities

• Facilitates medical reviews of prospective, retrospective, and concurrent appeals for denied prior authorizations
• Validates medical records and claims to ensure accurate coding and appropriate reimbursement to providers
• Prepares and presents cases for administrative hearings, collaborating with the chief medical officer 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
• Experience with ICD-10, CPT coding, and HCPC regulations
• Knowledge of state, federal, and third-party healthcare regulations
• Proficiency in Microsoft Office and applicable healthcare software