RN Medical Review Appeals Auditor

Job Summary

A company is looking for a Medical Review Clinical Appeals Auditor (RN) with a Government/Clinical Outpatient Focus.

Key Responsibilities

• Conducts clinical reviews and Appeals reviews on medical records and audit work
• Documents Appeals results and analyzes claims data to ensure audit accuracy
• Contributes to continuous improvement initiatives and supports training development

Required Qualifications

• Active unrestricted RN license in good standing with diversified nursing experience
• At least 5+ years of relevant experience in a provider or payer environment
• Experience with ICD-9/ICD-10 coding, HCPS/CPT coding, and medical billing
• Strong technical aptitude with intermediate to advanced Excel skills
• Prior experience in auditing, utilization management, or related functions is preferred