RN Medical Review Nurse

Job Summary

Working remotely in a dynamic environment, the full-time RN Medical Review Nurse will perform medical claims audit reviews, focusing on retrospective and prepayment audits for Government and Commercial Payers while collaborating with a multi-location team.

Key responsibilities:

• Auditing claims for medically appropriate services and applying relevant medical review guidelines
• Documenting findings and generating letters that articulate audit results
• Collaborating with the audit team to improve medical policies and minimize the number of appeals

Required qualifications:

• Active unrestricted RN license in good standing
• Minimum of five years of diversified nursing experience in inpatient or outpatient settings
• At least one year of experience performing medical records review
• One year of experience in healthcare claims with expertise in ICD-9/ICD-10 and CPT coding
• Strong preference for experience in utilization review for insurance companies or similar organizations