Registered Nurse Medical Reviewer

Job Summary

A company is looking for a Medical Review Nurse (RN) - Remote.

Key Responsibilities

• Facilitates clinical reviews of medical claims and appeals to ensure medical necessity and accurate billing
• Evaluates medical claims and records using clinical knowledge and regulatory guidelines
• Acts as a clinical resource for utilization management and provides training to clinical peers

Required Qualifications

• At least 2 years of clinical nursing experience, including 1 year in utilization review or medical claims review
• Active and unrestricted Registered Nurse (RN) license in the state of practice
• Knowledge of ICD-10, CPT coding, and HCPC regulations
• Experience with state, federal, and third-party regulations
• Analytical and decision-making skills