Nurse Reviewer - Williamsport, PA
$83,200–$83,200 year
Remote · Williamsport, Pennsylvania, United States
Job Summary
Nurse Reviewer for Medicaid medical necessity and policy reviews (Remote, PT 20-30 hrs/week). Perform comprehensive medical record reviews, screen and document evidence-based criteria per contract requirements, and evaluate claims using ICD-10, CPT, and HCPCS to determine medical necessity. Collaborate with Team Lead, Physician Peer Reviewer, and contract team; adhere to deadlines; maintain knowledge of evolving Medicaid policies; support training and maintain productivity and quality standards. Requires BSN with active RN license, 3-5 years of medical record review/utilization review experience, and strong interpersonal, analytical, and documentation skills.
Required Qualifications
- BSN with active RN licensure in good standing
- At least three to five years performing medical record review and/or abstraction
- Experience in utilization review and knowledge of Medicare/Medicaid policy
- Proficiency with Microsoft Office (Word, Excel, Outlook)
- Proficiency with Adobe PDF
- Strong written and verbal communication
- Ability to work independently and as part of a team
- HIPAA/HITECH compliance
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