California Licensed Medical Claim Nurse

A company is looking for a Medical Claim Review Nurse to perform clinical reviews of medical claims and ensure compliance with regulations. Key Responsibilities Conduct clinical/medical reviews of medical claims and previously denied cases to ensure medical necessity and accurate billing Document clinical review summaries and provide supporting documentation for payment decision modifications Serve as a clinical resource and provide training to peers while identifying members with special needs for appropriate referrals Required Qualifications Graduate from an Accredited School of Nursing Minimum 3 years of clinical nursing experience At least 1 year of experience in Utilization Review and/or Medical Claims Review Minimum 2 years of experience in Claims Auditing, Medical Necessity Review, and Coding Active, unrestricted State Registered Nursing (RN) license in good standing

Jun 12, 2025 - 01:40

A company is looking for a Medical Claim Review Nurse to perform clinical reviews of medical claims and ensure compliance with regulations. Key Responsibilities Conduct clinical/medical reviews of medical claims and previously denied cases to ensure medical necessity and accurate billing Document clinical review summaries and provide supporting documentation for payment decision modifications Serve as a clinical resource and provide training to peers while identifying members with special needs for appropriate referrals Required Qualifications Graduate from an Accredited School of Nursing Minimum 3 years of clinical nursing experience At least 1 year of experience in Utilization Review and/or Medical Claims Review Minimum 2 years of experience in Claims Auditing, Medical Necessity Review, and Coding Active, unrestricted State Registered Nursing (RN) license in good standing