Registered Nurse Medical Reviewer

Job Summary

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

Key Responsibilities

• Facilitates clinical reviews of medical claims and appeals to ensure medical necessity and accurate billing
• Validates medical records and claims, ensuring appropriate reimbursement and compliance with regulations
• Prepares and presents cases for administrative hearings and provides clinical support to peers and 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
• Knowledge of ICD-10, CPT coding, and healthcare regulations
• Experience with medical necessity review and claims auditing
• Proficiency in Microsoft Office and relevant software programs