California Licensed Clinical Claims Nurse

Job Summary

A company is looking for a Medical Claim Review Nurse.

Key Responsibilities

• Review medical records and claims for medical necessity and coding accuracy
• Conduct retrospective audits including DRG Validation, Level of Care, and Readmission reviews
• Collaborate with Medical Directors and assist Utilization Management teams

Required Qualifications

• Active, unrestricted RN license
• 3+ years of clinical nursing experience
• Experience with medical claims review, auditing, or utilization management preferred
• Familiarity with MCG/InterQual or willingness to train