Registered Nurse Medical Reviewer

Job Summary

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

Key Responsibilities

• Facilitates clinical/medical reviews of medical claims and appeals to ensure medical necessity and accurate billing
• Validates member medical records and claims, ensuring appropriate reimbursement and resolving 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
• Knowledge of ICD-10, CPT coding, and HCPC regulations
• Experience with state, federal, and third-party regulations
• Proficiency in Microsoft Office and relevant software programs