Utilization Review Nurse

Utilizing clinical expertise, the full-time Licensed Medical Review Nurse (LVN/LPN) will conduct medical reviews of claims and documentation to ensure medical necessity and compliance with regulations while working remotely on a MST/PST schedule. Key responsibilities Perform clinical reviews of medical claims and previously denied cases to assess medical necessity and billing accuracy Reevaluate claims and medical records, applying clinical knowledge and regulatory guidelines to determine appropriateness of services Validate medical records and claims to ensure correct coding and appropriate reimbursement for providers Required qualifications At least 2 years of clinical nursing experience, including 1 year in utilization review or medical claims review Active and unrestricted Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) license Knowledge of ICD-10, CPT coding, and HCPCS Experience with state and federal healthcare regulations Strong analytical and decision-making skills