RN Licensed Medical Reviewer

Job Summary

A company is looking for a Medical Reviewer III - Managed Care Project (MCP).

Key Responsibilities

• Conduct clinical reviews of medical records for the Medicaid Managed Care Project (MCP) and apply Medicaid guidelines for payment coverage determinations
• Develop review criteria and ensure claims are accurately paid based on project plans and documentation
• Compile Investigative Summary Reports and collaborate with healthcare professionals and regulatory agencies

Required Qualifications, Training, and Education

• Active Registered Nurse (RN) license from an accredited nursing school
• Minimum of 4 years of experience in utilization/quality assurance review and ICD-10-CM/CPT-4 coding
• Experience in coding and abstracting with knowledge of Diagnosis Related Groups (DRGs)
• Advanced understanding of medical terminology and Medicaid claims processing
• Familiarity with Medicaid coverage guidelines and payment methodologies