Registered Nurse Clinical Reviewer

Job Summary

Working remotely, the full-time Clinical Medical Review Nurse will manage the review of professional and institutional claims and provider appeals to determine eligibility for benefits, utilizing clinical judgment and medical policies.

Key responsibilities

• Research, review, and analyze claims using critical thinking and nursing clinical judgment for claims processing and adjudication
• Provide pricing for procedure codes requiring individual consideration and interpret medical information using CPT and HCPCS manuals
• Participate in medical policy meetings and review sessions with medical directors and committees as assigned

Required qualifications

• Bachelor's Degree in Nursing or equivalent experience (4 additional years of relevant work experience in lieu of a degree)
• Current RN licensure in the state of practice (VA, DC, or MD)
• At least 3 years of acute clinical experience, with prior case management or utilization review experience preferred
• Experience making clinical decisions related to post-claim submissions and appeals within a health payer organization
• Proficiency in Microsoft Office and web-based technology