Medical Review Nurse

Location: Sacramento, CA
Medical Review Nurse
Joining this team means you'll be surrounded by colleagues who are dedicated to meeting their own high standards, to inspiring their teammates and to making a positive impact on under-insured and uninsured individuals. The group is a fast, agile, customer-focused organization with a commitment to implementing the latest technologies.
Our client serves more than 55 million managed care members through their portfolio of high-quality commercial and government sponsored healthcare programs. The broad offering of programs that they provide has helped them to build both capacity and capability to successfully navigate a changing healthcare environment, while continuing to offer better health outcomes at lower costs.
Position Purpose:
Perform retrospective review of large hospital and physician claims for admission appropriateness, coding, length of stay, and pricing and review retrospective medical necessity appeals against medical review criteria to make benefit determinations.
Job Description:
  • Perform retrospective high dollar claims for benefit and pricing-determination.
  • Collect hospital medical records as appropriate and work with related hospital staff.
  • Work collaboratively with Finance Department to determine appropriateness of pricing.
  • Assist with other clinical functions of medical review.
  • Maintain appropriate records, files, documentation, etc.
  • Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. field.
  • Licensed or Registered Nurse. Advanced degree and/or certification preferred.
  • 2+ years in acute care nursing and utilization review.
  • Knowledge of managed care programs and practices required.
  • RN – Registered Nurse or LPN – Licensed Practical Nurse
Our client offers options that allow you to do more than just plan for retirement. Their programs allow shared success with employees.
  • 401(k) with company match
  • Employee stock purchase plan
  • Training and Learning Opportunities/Tuition Reimbursement/Educational Assistance
  • On-site fitness center or discount at local fitness centers (most locations)
  • Discounts for select local and national products and services, including cell phones, computers and more
  • Other amenities may be available, but vary by location
Equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
April A. Estes
Senior Recruiter
720-439-2609 Direct
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