Registered Nurse Clinical Reviewer
Virtual Vocations · Tulsa, OK
Job description
Working remotely, the full-time Clinical Medical Review Nurse will manage the review of professional and institutional claims and provider appeals to determine eligibility for benefits, utilizing clinical judgment and medical policies.Key responsibilitiesResearch, review, and analyze claims using critical thinking and nursing clinical judgment for claims processing and adjudicationProvide pricing for procedure codes requiring individual consideration and interpret medical information using CPT and HCPCS manualsParticipate in medical policy meetings and review sessions with medical directors and committees as assignedRequired qualificationsBachelor's Degree in Nursing or equivalent experience (4 additional years of relevant work experience in lieu of a degree)Current RN licensure in the state of practice (VA, DC, or MD)At least 3 years of acute clinical experience, with prior case management or utilization review experience preferredExperience making clinical decisions related to post-claim submissions and appeals within a health payer organizationProficiency in Microsoft Office and web-based technology
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