State Licensed Medical Review Nurse

Job Summary

A company is looking for a Medical Review Nurse II - Clinical Validation.

Key Responsibilities:

• Audit claims for medically appropriate services in inpatient and outpatient settings
• Document findings and generate letters articulating audit results
• Collaborate with the audit team and clients to improve medical policies and minimize appeals

Required Qualifications:

• Active unrestricted RN license in good standing
• Minimum of five years of diversified nursing experience in inpatient or outpatient settings
• One or more years of experience performing medical records review
• One or more years of experience in healthcare claims with expertise in coding (ICD-9/ICD-10, HCPCS/CPT)
• Strong preference for experience performing utilization review for an insurance company or similar organization