State Licensed Medical Review Nurse

Job Summary

Conducting clinical reviews of medical records, the full-time remote State Licensed Medical Review Nurse Analyst will ensure compliance with regulatory and payer guidelines, review claims for medical necessity, and provide education to providers on billing and documentation requirements.

Key responsibilities

• Perform detailed reviews of medical records to assess the medical necessity of services
• Review submitted claims to ensure correct coding and reimbursement based on Medicare guidelines
• Prepare clinical summaries and determinations, and educate providers according to the Targeted Probe and Educate (TPE) program

Required qualifications

• Associate's (ASN) or Bachelor's Degree in Nursing (BSN)
• Active RN license in good standing applicable to the state of practice
• One or more years of clinical experience in a healthcare setting
• Basic knowledge of medical/clinical review processes
• Solid computer skills with experience in MS Outlook, Teams, OneNote, Word, and Excel