Registered Nurse Medical Reviewer

Job Summary

A company is looking for a Medical Reviewer III for the Managed Care Project (MCP).

Key Responsibilities:

• Conduct clinical reviews of medical records and apply Medicaid guidelines for payment coverage determinations
• Review claims documentation to ensure accuracy and compliance with established criteria
• Compile Investigative Summary Reports and collaborate with healthcare professionals and regulatory agencies

Required Qualifications:

• Active Registered Nurse (RN) license from an accredited nursing school
• At least 4 years of experience in utilization/quality assurance review and ICD-10-CM/CPT coding
• Working knowledge of Diagnosis Related Groups (DRGs)
• Advanced understanding of medical terminology and Medicaid claims processing
• Knowledge of Medicaid coverage guidelines and payment methodologies