North Carolina Licensed Medical Review Analyst

Job Summary

A company is looking for a Medical Review Analyst.

Key Responsibilities

• Determines medical necessity, benefit eligibility, and reimbursement allowances for complex claims using clinical expertise and various software systems
• Ensures compliance with regulatory and accrediting requirements for reviews and determinations
• Identifies and reports billing patterns or utilization trends, and communicates with members and providers regarding claims status and determinations

Required Qualifications

• RN with a minimum of 3 years of clinical experience in various settings, or LPN with a minimum of 5 years of clinical nursing experience
• Must hold and maintain a valid North Carolina clinical license
• Experience in medical management and claims review processes is preferred
• Familiarity with medical literature, medical records, and clinical guidelines
• Ability to analyze and document clinical information effectively