Clinical Review Nurse - Medical Claims

Summary

We are seeking a detail-oriented and experienced Clinical Review Nurse to perform clinical assessments and reviews of medical claims to ensure accuracy, medical necessity, and compliance with established guidelines. In this role, you will evaluate clinical documentation, apply evidence-based criteria, and collaborate with healthcare providers and internal teams to support appropriate claim outcomes.

Duties and Responsibilities:

• Review medical claims and supporting clinical documentation for accuracy and medical necessity.
• Apply clinical guidelines and policies to evaluate treatments and procedures.
• Identify and flag discrepancies, coding issues, or lack of medical justification.
• Communicate with providers for additional information or clarification as needed.
• Collaborate with claims adjusters and medical directors to support claims decisions.
• Maintain up-to-date knowledge of regulatory requirements and clinical best practices.
• Work effectively with all other sub team members within MPM
• Comply with accuracy and timeliness standards in accordance with CMS, DHCS, & Health Plan regulations.
• Maintain knowledge of UM/Clinical policy and procedures
• Establish effective rapport during phone calls with other employees, professional support service staff, customers, clients, members, families, and physicians
• Attend all mandatory onsite and virtual meetings to ensure alignment with team goals, project updates, and organizational communication.

Minimum Job Requirements:

• Current California RN or LVN license
• 2+ years of experience in utilization management preferred
• Proficiency with Microsoft Office Programs; primarily Word and Excel
• Strong knowledge of medical terminology, clinical guidelines, and healthcare coding (ICD-10, CPT)
• EZ-CAP® knowledge a plus

Skills and Abilities:

• Excellent relationship management skills with the ability to communicate effectively with all stakeholders
• Strong organizational, task prioritization, and delegation skills
• Ability to collaborate successfully with all levels of the organization

Salary Range:

• LVN $36-$39; RN $42-$48 hourly