The US Registered Nurse (USRN) will support clinical review and healthcare operations by evaluating medical records, validating clinical necessity, and ensuring compliance with payer and regulatory standards. This role focuses on supporting accurate reimbursement outcomes through clinical documentation review, utilization management, and collaborative case assessment.

Key Responsibilities

• Conduct utilization review and evaluate medical necessity using established clinical criteria and guidelines.

• Review patient medical records to assess level of care, treatment plans, and medical services rendered.

• Ensure adherence to payer policies, CMS regulations, and healthcare industry standards.

• Perform prior authorization, concurrent review, and other utilization management activities as required.

• Support denial management by reviewing clinical cases and providing appeal-related clinical rec...