Registered Nurse Medical Reviewer

Job Summary

A company is looking for a Medical Reviewer (Medicare).

Key Responsibilities

• Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals
• Assess payment determinations using clinical information and established guidelines
• Provide clear, well-documented rationales for service approvals or denials

Minimum Qualifications

• Active, unrestricted RN license in the U.S. or active compact multistate RN license
• Associate Degree in Nursing or graduate of an accredited School of Nursing
• Two years of clinical experience plus at least two years in inpatient/outpatient settings, utilization/medical review, or quality assurance
• Strong clinical background in managed care and/or inpatient/outpatient settings
• Training and experience in ICD coding preferred