Claims Review Nurse, RN - Hybrid

As a Claims Review Nurse, RN, you will be responsible for ensuring the integrity of the adverse determination processes and accuracy of clinical decision-making. This role involves reviewing clinical information to determine medical necessity and appropriateness of care, collaborating with healthcare providers, and ensuring compliance with regulatory requirements. Your work will directly impact the quality and efficiency of patient care services.

Candidates should possess a current Registered Nurse (RN) license with a minimum of 3 years of clinical nursing experience. Strong knowledge of medical terminology, clinical guidelines, and healthcare regulations is essential. Excellent communication skills, attention to detail, and the ability to work collaboratively in a team environment are required. Experience in utilization management or case management is preferred.