RN Licensed Medical Reviewer

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