Registered Nurse Claims Reviewer

A company is looking for a Medical Claims Review Nurse.

Key Responsibilities

Analyze claims issues for claims pended to Medical Review and perform evidence-based research

Review and respond to medical claims appeals while coordinating with Clinical Centers of Excellence for necessary documentation

Conduct medical claims audits and report on claims metrics to ensure quality control

Required Qualifications

Registered Nurse (RN) with a BSN or BA / BS; experience in lieu of degree will be considered

5 years of experience in acute care settings and 2 years in Utilization Review (UR) / Utilization Management (UM) or Case Management

Experience with claims review in the acute care setting

Knowledge of coding, including ICD-10, CPT, and HCPCS

Familiarity with Federal programs and payors, including CMS, OWCP, and Tricare preferred