State Licensed Medical Claims Nurse

Job Summary

Passionate about making a difference, the full-time remote State Licensed Medical Claims Nurse will review medical claims to ensure services are medically necessary, analyze claims issues, and respond to provider appeals.

Key responsibilities:

• Analyzing claims issues for claims pended to Medical Review and performing evidence-based research
• Reviewing and responding to medical claims appeals while coordinating with Clinical Centers of Excellence to resolve claims issues
• Conducting medical claims audits and documenting Medical Management processes, including medical claims review

Required qualifications:

• Registered Nurse (RN) with a BSN or BA/BS; experience may be considered in lieu of a degree
• 5 years of experience in acute care settings and 2 years in Utilization Review (UR), Utilization Management (UM), or Case Management
• Experience with claims review in an acute care setting
• Knowledge of coding systems including ICD-10, CPT, and HCPCS
• Certified Case Manager (CCM) or similar certification preferred