Registered Nurse Medical Reviewer

Job Summary

To support the review of claims and provider appeals, the full-time Remote Clinical Medical Review Nurse will analyze medical information, assess claims eligibility, and participate in medical policy meetings while utilizing critical thinking and nursing judgment.

Key responsibilities

• Receives and analyzes professional and institutional claims to determine eligibility for benefits and support claims processing
• Provides pricing for procedure codes and interprets medical information using CPT and HCPCS manuals
• Conducts medical underwriting and risk assessment for potential subscribers and participates in relevant medical policy discussions

Required qualifications

• High School Diploma or GED
• Current RN - Registered Nurse state licensure or compact state licensure in VA, DC, or MD
• Minimum of 3 years acute clinical experience, with previous case management or utilization review experience
• Preferred Bachelor's degree in Nursing
• Preferred Certified Coding Professional (Inpatient) certification