Medicaid Clinical Reviewer - RN - Naperville Illinois

Company: VirtualVocations
Location: Naperville, Illinois
Posted On: 11/05/2024

A company is looking for a Medical Reviewer III - Managed Care Project (MCP).



Key Responsibilities

Conduct clinical reviews of medical records for Medicaid claims
Utilize Medicaid guidelines to determine payment coverage appropriateness
Compile written Investigative Summary Reports in collaboration with investigators


Required Qualifications and Education

Active Registered Nurse (RN) license from an accredited nursing school
At least 4 years of experience in utilization/quality assurance review and coding
Advanced knowledge of ICD-10-CM, CPT coding, and Medicaid coverage guidelines
Experience with Diagnosis Related Groups (DRGs) and Medicaid claims processing
Knowledge of NCPDP and prescription drug claims More...

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