Medical Claim Review Nurse

Join to apply for the Medical Claim Review Nurse role at Integrated Resources, Inc (IRI) . Job Description: Position is fully remote. Candidates can sit anywhere in the US and schedule will be M-F 9AM-5PM local time. The training schedule will be M-F 9AM-5PM EST. Daily responsibilities include reviewing medical patient records against standard medical criteria. Job Summary: Performs clinical/medical reviews of retrospective medical claim reviews, medical claims, and previously denied cases, to ensure medical necessity and accurate billing. Identifies and reports quality of care issues, refers members with special needs to appropriate programs, and assists with complex claim reviews. Documents clinical review summaries, provides supporting documentation for denials, and re-evaluates medical claims applying clinical knowledge and regulatory guidelines. Serves as a resource for utilization management and provides training and mentorship to peers and support staff. Prepares cases for hearings and represents clients during fair hearings. Qualifications: Minimum 3 years of clinical appeals review experience. At least 1 year of utilization review experience. Active, unrestricted RN license. Experience with itemized bill review and DRG preferred. Preferred certifications: Certified Clinical Coder, Medical Audit, Case Management, Healthcare Quality, or similar. Additional Details: Seniority level: Mid-Senior level Employment type: Full-time Job function: Other Industries: IT Services and Consulting This job posting is active and accepting applications. #J-18808-Ljbffr