Medical Claim Review Nurse (RN) - Remote

Overview

The Medical Claim Review Nurse is responsible for reviewing documentation to ensure medical necessity and appropriate level of care, validating medical records and claims to ensure correct coding and reimbursement.

In Short

• Review medical claims and documentation for medical necessity.
• Support the Appeals and Grievances department.
• Utilize clinical knowledge and experience in claims auditing.
• Document clinical review summaries and audit findings.
• Provide training and support to clinical peers.
• Identify quality of care issues.
• Assist with complex claim reviews.
• Maintain knowledge of state/federal regulations.
• Work remotely with required RN licensure in IL & WI.
• Full-time position with specific work hours.

Requirements

• Graduate from an Accredited School of Nursing.
• Minimum 3 years clinical nursing experience.
• Experience in Utilization Review and/or Medical Claims Review.
• Knowledge of claims auditing and medical necessity review.
• Active, unrestricted RN license in good standing.
• Bachelor’s Degree in Nursing preferred.
• Experience in Critical Care, Emergency Medicine, or Pediatrics preferred.
• Healthcare certifications preferred.

Benefits

• Competitive benefits and compensation package.
• Equal Opportunity Employer.