RN Medical Review Nurse in Jackson, MS

A company is looking for a Medical Review Nurse (RN) to support medical claim and internal appeals review activities. Key Responsibilities Facilitates clinical reviews of medical claims to ensure medical necessity and accurate billing Validates member medical records and claims for appropriate reimbursement and resolves escalated complaints Prepares and presents cases for administrative hearings and serves as a clinical resource for utilization management Required Qualifications At least 2 years of clinical nursing experience, including 1 year in utilization review or medical claims review 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 Analytic and decision-making skills