Medical Claim Reviewer (CGS, DMEC)

About the Role:

• Conducting pre- and post-payment medical reviews to ensure compliance.
• Assessing medical necessity, appropriateness, and reimbursement eligibility.
• Documenting decisions in accordance with regulatory and organizational requirements.

Key Responsibilities:

• Educate internal and external teams on medical review processes, coverage determinations, and coding requirements.
• Support quality control activities to meet corporate and team objectives.
• Provide guidance to LPN team members and support non-clinical staff through training and discussions.

Minimum Qualifications:

• Active, unrestricted RN license in the U.S.
• Associate Degree in Nursing OR Graduate of an accredited School of Nursing.
• Two years of clinical experience.