State Licensed Nurse Reviewer

Job Summary

To support client needs in hospital claims, the full-time remote State Licensed Nurse Reviewer will analyze claims data, identify billing errors, and negotiate adjustments with claims administrators on behalf of ASO clients.

Key Responsibilities

• Perform detailed audits of hospital claims, including itemized bills and medical records, to validate billing accuracy
• Serve as a subject matter expert in disputes with claims administrators, preparing documentation to support claim adjustments
• Analyze large claims data sets to identify trends and systemic overpayment patterns across client populations

Required Qualifications

• Hospital/Surgical/ICU Nursing background (RN) with clinical coding knowledge for DRG validation
• 5+ years of experience in hospital claims analysis or payment integrity, particularly with self-funded/ASO plans
• Strong knowledge of DRG methodology, UB-04 billing, and relevant coding systems (ICD-10-CM/PCS, CPT/HCPCS)
• Experience with stop loss insurance and understanding of claim adjustments' impact on reimbursement
• Proficiency in claims data analysis tools, particularly Excel; familiarity with SQL or claims analytics platforms is a plus