Registered Nurse Medical Reviewer

Job Summary

A company is looking for a Medical Claim Reviewer (CGS, DMEC).

Key Responsibilities

• Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals
• Assess payment determinations using clinical information and established guidelines
• Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement

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
• Strong clinical background in managed care, home health, rehabilitation, and/or medical-surgical settings
• Proficiency in Microsoft Office and word processing software