Senior Post-Service Clinical Review Nurse

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

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