Perform medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations
Make reasonable payment determinations based on clinical medical information and established criteria/protocol sets or clinical guidelines
Determines medical necessity, appropriateness, and/or reasonableness and necessity for coverage and reimbursement
Monitor process’s timeliness in accordance with contractor standards
Document medical rationale to justify payment or denial of services and/or supplies
Educate internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines
Participate in quality control activities supporting corporate and team-based objectives
Provide guidance, direction, and input as needed to LPN team members
Provide education to non-medical staff through discussions, team meetings, classroom participation, and feedback
Assist with special projects and specialty duties and responsibilities as assigned by management

Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
Associate degree
Nursing OR Graduate of an accredited School of Nursing
Two years of clinical experience as an RN
Working knowledge of word processing software
Ability to work independently, prioritize effectively, and make sound decisions
Good judgment skills
Demonstrated customer service and organizational skills
Demonstrated oral and written communication skills
Analytical or critical thinking skills
Ability to handle confidential or sensitive information with discretion
Five years of varied RN nursing experience to include: Medical/Utilization Review, Quality Assurance, Emergency, Critical Care, or Medical/Surgical experience, strongly preferred
Medicare or claims experience a plus
Ability to use multiple Windows-based programs simultaneously

RN Medical Reviewer II – RCD Medicare

Key skills