RN Medical Reviewer II

Job Summary

A company is looking for an RN Medical Reviewer II (RCD Medicare).

Key Responsibilities

• Perform medical claim reviews for complex services and make payment determinations based on clinical information and established guidelines
• Determine medical necessity and document rationale for coverage decisions, while educating staff on medical reviews and coding procedures
• Participate in quality control activities and provide guidance to team members, assisting with special projects as needed

Required Qualifications, Training, and Education

• Active RN licensure in the state hired or active compact multistate RN license
• Associate degree in Nursing or graduation from an accredited School of Nursing
• Two years of clinical experience as an RN
• Working knowledge of word processing software and ability to work independently
• Five years of varied RN nursing experience, including Medical/Utilization Review, is preferred