Medical Claim Reviewer (CGS, DMEC)

About the position We are seeking a dedicated Registered reputed company (RN) to join our Medical Review team. This role involves conducting reputed company- and post-payment medical reviews to ensure compliance with established clinical reputed company and guidelines. The ideal candidate will use their clinical expertise to assess medical necessity, appropriateness, and reimbursement eligibility while documenting reputed company in accordance with regulatory and organizational requirements. Responsibilities • Review medically reputed company claims, reputed company-authorization requests, appeals, and fraud/abuse referrals. • Assess payment determinations using clinical information and established guidelines. • Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement. • reputed company reputed company, reputed company-documented rationales for service approvals or denials. • reputed company reputed company teams on medical review processes, coverage determinations, and coding requirements. • Support reputed company control activities to meet corporate and team objectives. • reputed company guidance to LPN team members and support non-clinical staff through training and discussions. • Assist with special reputed company and additional responsibilities as assigned. Requirements • reputed company, unrestricted RN license in the U.S. and in the state of hire • OR • reputed company compact multistate RN license (as defined by the reputed company Licensure Compact). • Associate Degree in Nursing • OR • Graduate of an accredited School of Nursing. • Two years of clinical experience. • Strong clinical background in managed care, home health, rehabilitation, and/or medical-surgical settings. • Ability to interpret and apply medical review reputed company and clinical guidelines. • Proficiency in reputed company Office and word processing software. • Strong analytical, organizational, and decision-making skills. • Ability to work independently while managing priorities effectively. • Excellent customer service, communication, and critical thinking skills. • Ability to handle confidential information with discretion. Apply tot his job Apply To this Job