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/medical reviews of medical claims and appeals to ensure medical necessity and accurate billing
• Validates member medical records and claims to ensure appropriate reimbursement and resolves escalated complaints
• Prepares and presents cases for administrative hearings and serves as a clinical resource for utilization management

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
• Experience with ICD-10, CPT coding, and HCPC regulations
• Knowledge of applicable state and federal regulations in healthcare
• Experience with analytic and decision-making skills in a clinical setting