North Carolina RN Medical Reviewer

Job Summary

A company is looking for an RN Medical Reviewer III to perform medical reviews and support medical claims and utilization practices.

Key Responsibilities

• Conduct medical claim reviews and determine medical necessity based on clinical guidelines
• Educate internal and external staff on medical reviews, terminology, and coding procedures
• Participate in quality control activities and provide guidance to team members

Required Qualifications, Training, and Education

• Associate's degree in a job-related field or equivalent from an accredited School of Nursing
• Active, unrestricted RN licensure in the state of hire or compact multistate RN license
• 2 years of clinical experience plus 1 year in utilization/medical review, or 3 years of clinical experience
• Proficiency in Microsoft Office and ability to work independently
• Experience handling confidential information with discretion