Reviews clinical claims through post-service evaluation, assesses medical necessity and policy compliance, and determines whether retrospective claims should be paid according to plan benefits and policies. Collaborates with claims teams, physicians, pharmacists, and prior authorization staff.
Responsibilities
Review clinical claims and retrospective services.
Evaluate medical necessity and compliance with benefits and policies.
Determine appropriate claim payment outcomes.
Collaborate with claims, physician, pharmacy, and prior authorization teams.
Requirements
Active RN or LVN license.
Minimum of five years of experience demonstrating strong clinical judgment.
Experience with post-service review, prior authorization, or concurrent review.
Highly detail-oriented.
Summary Qualification
Licensed nursing professional with clinical claims review experience.
Strong knowledge of medical necessity and benefits or policy requirements.
Prior post-service review experience preferred.
Skill
Clinical judgment.
Claims review.
Medical necessity evaluation.
Strong attention to detail.
Computer skills and familiarity with clinical or claims systems.
Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.