Registered Nurse Claims Reviewer

Job Summary

A company is looking for a Medical Claims Review Nurse.

Key Responsibilities

• Review and analyze medical claims to ensure services are medically necessary
• Respond to medical claims appeals and coordinate with Clinical Centers of Excellence for documentation
• Conduct audits and research to maintain quality control and report on claims metrics

Required Qualifications

• Registered Nurse (RN) with a BSN preferred or BA/BS considered
• 5 years of experience in an acute care setting
• 2 years of experience in Utilization Review (UR) or Case Management preferred
• Knowledge of medical coding (ICD-10, CPT, HCPCS) and federal programs
• Experience with Quality Assurance review of medical claims preferred