RN Appeals Medical Review Nurse

Job Summary

Utilizing clinical expertise, the full-time RN Appeals Medical Review Nurse will review medical documentation for necessity and appropriateness of care, ensuring compliance with MCG/InterQual and relevant regulations while working remotely on a PST schedule.

Key responsibilities

• Facilitates medical review of appeals for denied prior authorizations across various cases, including inpatient and outpatient
• Reevaluates medical claims and records to assess appropriateness of services and ensure accurate billing
• 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, with 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 HCPC
• Experience with state, federal, and third-party regulations
• Analytic and decision-making skills relevant to clinical assessments