Home /
Medical Reviewer, Registered Nurse
– All Latest Jobs Today
Medical Reviewer, Registered Nurse
Other Jobs To Apply
No other job posts for this day.
Job Description:
Review and interpret medical records and clinical documentation to determine medical necessity and appropriateness of healthcare services
Provide clinical review support for Treatment Authorization Requests (TARs) and other authorization activities
Support medical review activities related to medical policy, claim adjudication, drug utilization review, and other healthcare program requirements
Apply professional nursing principles, clinical judgment, medical policies, and established utilization guidelines when completing reviews
Review documentation to determine whether requested services, procedures, supplies, and equipment meet coverage and clinical requirements
Document review findings, decisions, and supporting clinical rationale accurately and timely
Determine approvals within established guidelines or refer cases to physicians or other appropriate clinical professionals
Apply knowledge of hospital routines, medical services, medical supplies, and appropriate clinical uses
Collaborate with physicians, pharmacists, nurses, and other healthcare professionals
Maintain current knowledge of clinical criteria, medical policies, procedures, and regulatory requirements
Meet established quality, accuracy, productivity, and turnaround-time standards
Work primarily from a home office supporting Medical Review Services for California healthcare programs
Navigate multiple systems and applications to complete reviews and document findings
Requirements:
Active and unrestricted Registered Nurse (RN) license to practice in the State of California, in good standing
Minimum of two (2) years of professional nursing experience
Possession of a Master’s Degree in Nursing may substitute for one (1) year of the required professional nursing experience
Knowledge of professional nursing principles and techniques, hospital routines, and medical supplies and their uses
Training and/or certification in wound and ostomy care preferred
Strong clinical judgment and ability to interpret medical records and supporting clinical documentation
Experience with medical review, utilization review, medical necessity review, prior authorization, Treatment Authorization Requests (TARs), or claims review preferred
Strong written and verbal communication skills
Ability to navigate multiple computer systems and applications
Ability to maintain required professional licenses, certifications, and credentials in active, unrestricted, and good-standing status
