Medical Review Nurse

Position Overview :

The Medical Review Nurse . The role ensures claims meet emergency criteria, medical necessity, and correct coding, coordinating with providers for second-level reviews as needed.

Key Responsibilities :

• Perform claims review / adjudication using industry standards.
• Determine if claims meet emergency criteria, medical necessity, and correct coding (CPT / HCPCS / Revenue codes).
• Evaluate appropriate level of care and length of stay.
• Prepare reports, analyze trends, and savings.
• Participate in research and special projects.
• Coordinate with providers and internal teams as required.

Knowledge & Skills Required :

Requirements :

Preferred :

Compliance Documents (Submit in one PDF) :

Specialty :

Medical Claims Review / Utilization Review / Managed Care Nursing