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 while analyzing medical information to support claims processing and adjudication.

Key responsibilities

• Researches, reviews, and analyzes claims using nursing clinical judgment and corporate policies
• Provides pricing for procedure codes requiring individual consideration and interprets medical information utilizing CPT and HCPCS manuals
• Participates in medical policy meetings and collaborates with medical directors and committees on special projects

Required qualifications

• Bachelor's Degree in Nursing or 4 additional years of relevant work experience in lieu of a degree
• RN - Registered Nurse - State Licensure and/or Compact State Licensure in VA, DC, or MD
• 3 years of acute clinical experience, including case management, discharge planning, or utilization review
• Previous experience with clinical decisions related to post-claim submissions or appeals within a health payer organization