Registered Nurse Medical Reviewer

Job Summary

A company is looking for a Medical Review Nurse (RN) to provide support for medical claim and internal appeals review activities.

Key Responsibilities

• Facilitates clinical reviews of medical claims and appeals to ensure medical necessity and accurate billing
• Reevaluates medical claims and records, applying clinical knowledge and regulatory requirements
• Serves 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
• Experience with state, federal, and third-party regulations
• Analytic and decision-making skills