Clinical Review Nurse 5

Wollborg Michelson Personnel Service Inc; Rancho Cordova (CA); On-site; USD 95,000 - 125,000; Full time

Job summary

Wollborg Michelson Recruiting is seeking a Post-Service Clinical Review Nurse to assess medical necessity, policy compliance, and coding accuracy across claims and medical records. This role collaborates with claims and appeals teams and supports appropriate provider payments to ensure quality member care.

The ideal candidate has a nursing license, an associate degree, and substantial experience in clinical reviews, post-service processes, and regulatory requirements, with strong communication

Qualifications

• Associate degree in nursing is required.
• Bachelor’s degree in nursing is preferred.
• Current nursing license required.
• At least 10 years of relevant experience required.
• Strong clinical background with experience reviewing outpatient procedures and tests.

Responsibilities

• Perform clinical claim reviews and initial claim-level determinations using evidence-based guidelines, medical policies, and nationally recognized clinical criteria.
• Review outpatient services, laboratory services, durable medical equipment, and medications for medical necessity, coding accuracy, policy compliance, and contract compliance.
• Prepare and present cases to the Medical Director for oversight and medical necessity determinations.
• Communicate determinations to providers and members in compliance with federal and accreditation requirements.
• Develop member-centered documentation and correspondence that reflects review determinations and meets regulatory standards.
• Triage and prioritize cases to meet required turnaround times and productivity goals.
• Identify potential quality-of-care issues, service delays, or treatment delays and intervene when clinically appropriate.
• Refer cases to Case Management, Disease Management, Appeals and Grievances, and Quality departments as needed.
• Support the development and implementation of standardized approaches to improve retrospective clinical claims review.
• Perform other duties as assigned.

Skills

Clinical review experience

Outpatient review

Medical policy knowledge

Communication skills

Documentation skills

Independent work

Education

Associate degree in nursing

Bachelor's degree in nursing (preferred)

Job description

Post-Service Clinical Review Nurse Job Summary

The Post-Service Clinical Review Nurse reviews claims and medical records to assess medical necessity, medical policy compliance, benefits, and clinical coding. This role manages the review process through final appeals, collaborates with claims and appeals teams, supports appropriate provider payments, and helps ensure members receive quality care.

Responsibilities

• Perform clinical claim reviews and initial claim-level determinations using evidence-based guidelines, medical policies, and nationally recognized clinical criteria.
• Review outpatient services, laboratory services, durable medical equipment, and medications for medical necessity, coding accuracy, policy compliance, and contract compliance.
• Prepare and present cases to the Medical Director for oversight and medical necessity determinations.
• Communicate determinations to providers and members in compliance with federal and accreditation requirements.
• Develop member-centered documentation and correspondence that reflects review determinations and meets regulatory standards.
• Triage and prioritize cases to meet required turnaround times and productivity goals.
• Identify potential quality-of-care issues, service delays, or treatment delays and intervene when clinically appropriate.
• Refer cases to Case Management, Disease Management, Appeals and Grievances, and Quality departments as needed.
• Support the development and implementation of standardized approaches to improve retrospective clinical claims review.
• Perform other duties as assigned.

Requirements

• Associate degree in nursing required.
• Bachelor s degree in nursing preferred.
• Current nursing license required.
• At least 10 years of relevant experience required.
• Skill Strong clinical background with experience reviewing outpatient procedures and tests.
• Knowledge of medical necessity, clinical coding, medical policies, and claims review.
• Ability to use technology and clinical review systems effectively.
• Ability to work independently and manage multiple cases.
• Experience with post-service reviews and prior authorization processes preferred.
• Strong communication, organization, critical-thinking, and documentation skills.

Summary Qualification

Licensed nurse with extensive clinical review experience. Proven ability to evaluate claims and medical records for medical necessity and compliance. Ability to coordinate with providers, members, physicians, and internal departments. Demonstrated commitment to quality care, regulatory compliance, and continuous process improvement.

Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.