Medical Review Nurse
Core
Clinical review of medical claims and post-service appeals for Medicare Advantage members, ensuring coverage, medical necessity, and appropriateness of care.
Role type
Senior IC Medical Review Nurse (Medicare/Medicaid)
Builds
Clinical adjudication decisions and appeals management for a nonprofit Medicare Advantage plan.
Domain
US Healthcare / Medicare Advantage / Clinical Utilization Review
Required skills
Clinical decision making, CMS guidelines interpretation, medical record review, claims analysis, utilization review, Medicare/Medicaid policy knowledge
Preferred skills
Certified Professional Coder (CPC), Bachelor's Degree, AI curiosity
Technologies
Computer systems for claims processing
Responsibilities
Review and analyze pre and post payment complex health care claims; Perform audits/reviews of medical claims and identify need for medical record review; Provide guidance to staff and interpret CMS guidelines; Conduct review of claims data and medical records to make clinical decisions on coverage, medical necessity, and utilization; Route identified clinical/risk issues to appropriate personnel; Review/prepare potential claims denials in conjunction with Medical Director; Collaborate with Medical Director on adjudication of claims and appeals; Participate in special projects/workgroups/committees (e.g., IRE)
Seniority
Mid-Senior level, hands-on IC