State Licensed Clinical Review Nurse

Job Summary

A company is looking for a Clinical Review Nurse.

Key Responsibilities

• Conduct clinical review and audit of complex medical bills to ensure medical necessity and compliance with guidelines
• Communicate with medical providers and assist management in identifying opportunities based on billing environments
• Oversee specialized pharmacy review initiatives and negotiate high dollar bills not subject to fee schedule reductions

Required Qualifications

• Active and unencumbered professional nursing license (RN preferred or LPN/LVN with experience)
• Three or more years of bill audit experience, including knowledge of workers' compensation laws and fee schedules
• Minimum of three years' clinical experience in operating room, orthopedics, ER, or similar fields
• Certification as a Medical Coder is required
• Experience with ICD-9, ICD-10, and CPT coding procedures