Medical Claim Review Nurse

Job Title: Medical Claim Review Nurse
Location: Orlando, FL
Job Duration: 3 Months+ (with High possibility of Conversion/Extension)

Work Hours: Shift flexibility between 6:00 AM – 6:00 PM (local time zone after training)
Schedule: Full-time
Travel: None
 
Job Summary:
The Clinical Claims Review Nurse (RN) is responsible for performing detailed clinical reviews of retrospective medical claims, including appeals and complex claim cases. This role ensures that services meet medical necessity criteria and are compliant with regulatory, coding, and billing guidelines. Nurses in this role collaborate closely with physicians, medical directors, and other healthcare professionals to drive accurate reimbursement and quality care outcomes.
 
Key Responsibilities:

• Perform clinical reviews of medical claims, appeal cases, and retrospective claim audits to determine medical necessity and appropriate billing
• Apply clinical knowledge to identify issues such as DRG validation, readmissions, and level of care
• Utilize guidelines such as MCG, InterQual, federal/state regulations, and client-specific policies
• Document audit findings, clinical summaries, and payment recommendations in the system
• Present and support denial/modification decisions with appropriate documentation and clinical criteria
• Participate in quality of care reviews and identify potential patient safety concerns
• Engage with Medical Directors and interdisciplinary teams for case reviews
• Provide clinical training and guidance to internal staff and peers as needed
• Refer members with special needs to the appropriate internal programs based on protocols

 
Qualifications:
Education:

• Graduate of an accredited School of Nursing (Required)

Licensure:

• Active, unrestricted Registered Nurse (RN) license in the state of residence (Required)

Experience:

• Minimum 3 years of clinical nursing experience
• At least 1 year of experience in Utilization Review and/or Medical Claims Review
• Minimum 2 years in Claims Auditing, Medical Necessity Review, and CPT/HCPCS Coding
• Familiarity with state and federal regulatory healthcare requirements

 
Preferred Experience:

• Experience with behavioral health and outpatient claims
• Background in reviewing clinical documentation for alignment with CPT/HCPCS coding
• Familiarity with MCG and InterQual criteria
• Strong knowledge of federal/state coding and billing compliance

 
Key Skills & Abilities:

• Strong critical thinking and clinical judgment skills
• Ability to interpret medical documentation in support of claims validation
• Excellent verbal and written communication skills
• Competency using clinical and claims review systems
• Detail-oriented with strong organizational and documentation skills