Arizona Licensed Medical Review Nurse in Boston, MA

A company is looking for a Medical Review Nurse (RN). Key Responsibilities Facilitates clinical / medical reviews of medical claims and appeals to ensure medical necessity and accurate billing Validates member medical records and claims, ensuring appropriate reimbursement and identifying quality of care issues Serves as a clinical resource, providing training and support to peers and preparing cases for administrative hearings Required Qualifications At least 2 years of clinical nursing experience, including 1 year in utilization review or related fields Active and unrestricted Registered Nurse (RN) license in the state of practice Knowledge of ICD-10, CPT coding, and HCPC regulations Experience working within state, federal, and third-party regulations Analytical and decision-making skills, with proficiency in Microsoft Office suite