Registered Nurse Medical Reviewer
New
B
Broadway VenturesHealthcare claims review
Remote, U.S.Full-TimeMiddle
Salary62,000 - 65,000 USD per year
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Job Details
- Experience
- Minimum two years of clinical experience plus at least two years in one of the following: Inpatient/Outpatient settings, Utilization/Medical Review, Intensive care (ICU/ER), or Quality Assurance. Preferred: Three years of clinical nursing experience in Inpatient/Outpatient settings, Utilization Review, Medical Review, or Quality Assurance.
- Required Skills
- Microsoft OfficeQuality Assurance
Requirements
- Maintain an active, unrestricted RN license in the U.S. and in the state of hire, or an active compact multistate RN license as defined by the Nurse Licensure Compact.
- Hold an Associate Degree in Nursing or be a graduate of an accredited School of Nursing.
- Have a minimum of two years of clinical experience plus at least two years in an inpatient/outpatient setting, Utilization/Medical Review, intensive care (ICU/ER), or Quality Assurance.
- Bring a strong clinical background in managed care and/or inpatient/outpatient settings.
- Be able to interpret and apply medical review criteria and clinical guidelines.
- Have proficiency in Microsoft Office and word processing software.
- Demonstrate analytical, organizational, decision-making, and critical-thinking skills.
- Be able to work independently and manage priorities effectively.
- Handle confidential information with discretion.
- Preferred: Three years of clinical nursing experience in Inpatient/Outpatient settings, Utilization Review, Medical Review, or Quality Assurance.
- Preferred: Proficiency using multiple screens and software programs simultaneously, and training and experience in ICD coding.
Responsibilities
- Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
- Assess payment determinations using clinical information and established guidelines.
- Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement.
- Provide clear, well-documented rationales for service approvals or denials.
- Educate internal and external teams on medical review processes, coverage determinations, and coding requirements.
- Support quality control activities to meet corporate and team objectives.
- Assist with special projects and additional responsibilities as assigned.
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