Job Description
A company is looking for a Medical Review Nurse (RN) to support medical claim and internal appeals review activities remotely.
- Key Responsibilities
- Facilitates clinical reviews of medical claims and appeals to ensure medical necessity and accurate billing
- Validates medical records and claims for appropriate reimbursement and resolves escalated complaints regarding utilization management
- Prepares and presents cases for administrative hearings and serves as a clinical resource for utilization management inquiries
- Required Qualifications
- At least 2 years of clinical nursing experience, including 1 year in utilization review or medical claims review
- Active and unrestricted Registered Nurse (RN) license in the state of practice
- Experience with ICD-10, CPT coding, and HCPC regulations
- Analytic and decision-making skills with experience in relevant state and federal regulations
- Proficiency in Microsoft Office suite and applicable software programs
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