Utilization Management Claims Review Nurse RN II

The Utilization Management (UM) Claims Review Nurse RN II is responsible for conducting clinical review of medical claims to ensure services were medically necessary, appropriately documented, accurately billed, and compliant with established clinical policies and regulatory standards.

Requirements

• Perform claims pre-payment review by supporting the Claims team in evaluating flagged claims prior to adjudication
• Conduct comprehensive retrospective reviews, applying established clinical criteria, policies, and regulatory guidelines
• Complete Provider Dispute Review (PDR) clinical evaluations for disputed claims requiring medical necessity scrutiny
• Apply internal and external clinical policies to ensure compliance with guidelines intended to limit fraud, waste, and abuse (FWA)
• Maintain productivity and quality standards consistent with departmental expectations

Benefits

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)