RN Clinical Claims Review Specialist – Appeals & Compliance

Integrated Resources, Inc.; Orlando (FL); On-site; USD 80,000 - 85,000; Full time

Job summary

A healthcare consulting firm is seeking a Medical Claim Review Nurse in Orlando, FL. This role involves reviewing medical claims for compliance and medical necessity, requiring an active RN license and a minimum of three years of nursing experience. Key responsibilities include conducting audits, documenting findings, and collaborating with medical teams. This is a full-time position with a potential for extension.

Qualifications

• 3+ years of clinical nursing experience.
• 1+ years in Utilization Review or Medical Claims Review.
• 2+ years in Claims Auditing, Medical Necessity Review, and coding experience.

Responsibilities

• Perform clinical reviews of medical claims and audits.
• Document audit findings and clinical summaries.
• Engage with Medical Directors for case reviews.

Skills

Critical thinking

Clinical judgment

Communication skills

Detail-oriented

Organizational skills

Education

Graduate of an accredited School of Nursing

Job description

A healthcare consulting firm is seeking a Medical Claim Review Nurse in Orlando, FL. This role involves reviewing medical claims for compliance and medical necessity, requiring an active RN license and a minimum of three years of nursing experience. Key responsibilities include conducting audits, documenting findings, and collaborating with medical teams. This is a full-time position with a potential for extension.