REMOTE MEDICAL CLAIM REVIEW REGISTERED NURSE – MI

✨ About The Role

- Responsible for reviewing documentation to ensure medical necessity and appropriate level of care using various guidelines and regulations - Conducts clinical/medical reviews of retrospective medical claim reviews, denied cases, and appeals to ensure accuracy in billing and claims processing - Identifies and reports quality of care issues and assists with complex claim reviews, including DRG validation and inpatient readmission cases - Documents clinical review summaries, audit findings, and provides supporting documentation for denial or modification of payment decisions - Serves as a clinical resource for various stakeholders, provides training and support to peers, and identifies members with special needs for appropriate program referrals

⚡ Requirements

- Minimum 3 years of clinical nursing experience required, with at least one year of Utilization Review and/or Medical Claims Review experience - Familiarity with state/federal regulations and coding experience is essential for success in this role - Ability to work independently in a high-volume environment and meet metric production goals - Strong computer skills are necessary, including the ability to navigate between multiple programs simultaneously - Michigan RN license is required, and additional certifications such as Certified Clinical Coder are preferred