State Licensed Medical Review Nurse

Job Summary

Working remotely in a fast-paced environment, the full-time State Licensed Medical Review Nurse will perform medical claims audit reviews for Government and Commercial Payers, documenting findings and supporting the appeals process as needed.

Key Responsibilities:

• Auditing claims for medically appropriate services in inpatient settings while applying relevant medical review guidelines
• Documenting findings and generating letters that articulate audit results
• Collaborating with the audit team to identify vulnerabilities and improve audit workflows

Required Qualifications:

• Active/unrestricted RN license with an associate or bachelor's degree in nursing
• At least 2 years of experience in inpatient claims auditing or Clinical Documentation Integrity
• Certification as CCDS, CDIP, CCS, or CIC is required
• Deep knowledge of ICD-9, ICD-10, CPT-4, or HCPCS coding
• Experience with utilization management systems or clinical decision-making tools