State Licensed Medical Review Nurse

Job Summary

Working remotely, the full-time State Licensed Medical Review Nurse will perform medical claims audit reviews for government clients, focusing on both retrospective and prepayment audits while collaborating with a multi-location team.

Key Responsibilities:

• Auditing claims for medically appropriate services in inpatient and outpatient 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 medical policies and provider education

Required Qualifications:

• Active unrestricted RN license in good standing
• Minimum of five years of diversified nursing experience in inpatient or outpatient settings
• One year of experience performing medical records review
• One year of experience in health care claims with expertise in ICD-9/ICD-10 coding and medical billing
• Strong preference for experience in utilization review for an insurance company or similar organization