Utilization Management Claims Review Nurse RN II

Job Summary

The Utilization Management (UM) Claims Review Nurse RN II is responsible for conducting clinical review of medical claims to ensure services were medically necessary, appropriately documented, accurately billed, and compliant with established clinical policies and regulatory standards.

This position supports payment integrity initiatives through retrospective and pre-payment review processes, helps reduce unnecessary denials, and monitors for potential fraud, waste, and abuse (FWA).

The UM Claims Review Nurse RN II collaborates closely with internal teams to ensure accurate adjudication and compliance. This position collaborates closely with internal stakeholders and external entities to support compliance with state, federal, and accreditation requirements. 

Duties

Perform claims pre-payment review by supporting the Claims team in evaluating flagged claims prior to adjudication to ensure services are medically necessary, documentation supports billed services, coding is accurate and aligned with authorization when applicable, and unnecessary denials are reduced through accurate clinical validation.

Conduct comprehensive retrospective reviews, applying established clinical criteria, policies, and regulatory guidelines to determine medical necessity and appropriateness of services rendered.

Complete Provider Dispute Review (PDR) clinical evaluations for disputed claims requiring medical necessity scrutiny and clinical determination.

Apply internal and external clinical policies, including those developed by the Clinical Policy team, to ensure compliance with guidelines intended to limit fraud, waste, and abuse (FWA). Ensure adherence to federal and state regulations, and accreditation standards.

Monitor trends related to contested claims and identify potential FWA concerns; escalate findings in accordance with organizational compliance protocols.

Collaborate with internal teams to support payment integrity initiatives.

Provide clear, well-documented clinical rationales supporting approval, denial, or adjustment decisions.

Maintain productivity and quality standards consistent with departmental expectations.

Participate in audits, regulatory readiness activities, and quality improvement initiatives as assigned. Document review outcomes clearly and accurately within designated systems, ensuring audit readiness and traceability.

Remain current with evolving clinical guidelines, coding standards, reimbursement methodologies, and regulatory requirements.

Perform other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 5 years of experience in Clinical Nursing.

At least 3 years of experience with Medi-Cal and Medicare in a managed care environment.

Experience in performing and creating clinical documentation.

Experience in regulatory compliance for a health plan.

Preferred: 

Experience with Provider Dispute Review (PDR) processes.

Experience applying clinical guidelines (e.g., InterQual, MCG, or internally developed criteria) in processes.

Prior experience in payment integrity, compliance, or fraud, waste, and abuse (FWA) monitoring.

Skills

Required:

Knowledge of medical necessity criteria, reimbursement principles, and managed care operation.

Working knowledge of clinical policies.

Working knowledge of CPT/HCPC Codes, and ICD-10.

Proficient in claims processing systems and electronic medical record platforms.

Strong problem-solving skills and the ability to identify discrepancies, assess risk, and recommend actionable solutions.

Strong verbal and written communication skills.

Ability to work independently with a high degree of initiative, organization, and self-direction.

Ability to work effectively with diverse teams in cross-functional work groups.

Ability to multitask, re-prioritize tasking, and streamline day-to-day operations.

Familiarity with regulatory and accreditation standards (e.g., CMS, Medi-Cal, NCQA).

Understanding of the managed care industry and market conditions.

High organizational and time-management skills.

Preferred:

Strong analytical and investigative skills with the ability to synthesize clinical and claims information into clear, defensible determinations are highly valued.

Advanced knowledge of medical necessity criteria tools such as InterQual or MCG.

Extensive knowledge in claims reviews includes retrospective reviews, pre-payment claims review, and medical necessity determinations.  

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information