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 identifying quality of care issues
• Serves as a clinical resource for utilization management and provides training and support 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
• Experience with ICD-10, CPT coding, and HCPC regulations
• Knowledge of state and federal healthcare regulations
• Proficiency in Microsoft Office suite and relevant software programs