Registered Nurse Medical Reviewer

Job Summary

To support the Medicaid Managed Care Project, the full-time Medical Reviewer III will conduct clinical reviews of medical records, apply Medicaid guidelines for payment coverage determinations, and collaborate with healthcare professionals, all while working remotely.

Key responsibilities:

• Develop review criteria based on Medicaid state and federal laws for claims review
• Analyze claims to ensure accurate payment and documentation compliance
• Compile Investigative Summary Reports and provide expert witness testimony as needed

Required qualifications:

• Active Registered Nurse (RN) license from an accredited nursing school
• Minimum of 4 years' experience in utilization/quality assurance review and ICD-10-CM/CPT coding
• Advanced knowledge of medical terminology and Medicaid claims processing
• Proficiency in Microsoft Word, Excel, and internet applications
• Experience with Diagnosis Related Groups (DRGs) and Medicaid coverage guidelines