RN Appeals Medical Review Nurse

Job Summary

Utilizing clinical knowledge and experience, the full-time RN Appeals Medical Review Nurse will review documentation to ensure medical necessity and appropriate levels of care while working remotely.

Key responsibilities

• Facilitates medical reviews of appeals for denied prior authorizations, including inpatient, outpatient, and pharmaceutical cases
• Reevaluates medical claims and associated records to assess the appropriateness of services provided and length of stay
• 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
• Knowledge of ICD-10, CPT coding, and HCPCS
• Experience with state, federal, and third-party regulations
• Analytic and decision-making skills