Clinical Review Nurse I (US)
Hybrid
Core
Reviewing and making complex medical determinations on claims to determine benefit eligibility.
Role type
Clinical Review Nurse I
Builds
Medical determinations for federal program claims
Domain
Healthcare / Insurance Claims
Required skills
Nursing assessment, medical policy interpretation, claim review, benefit eligibility determination, clinical experience
Preferred skills
Medical management, Utilization Review, advanced nursing degree
Technologies
Medical policy systems, claims administration platforms
Responsibilities
Assess necessity and reasonableness of items in valid claims, apply medical policy to determine benefit coverage
Seniority
Entry-level, individual contributor