Claims Medical Reviewer RN I

Fargo, North Dakota
Join our team!
Sep 09, 2020
Job Type
Full Time
Job Summary

The Claims Medical Reviewer I (RN) is responsible for interpreting, researching and processing institutional and professional claims. This role ensures services are medically appropriate and necessary and that proper medical policies, criteria and guidelines are followed in addition to coding, billing and reimbursement guidelines and policies. The Claims Medical Reviewer I (RN) utilizes medical/nursing knowledge, critical thinking and research skills to identify trends and aberrancies related to medical necessity and coding and billing practices. This position serves as a medical resource for the organization by providing guidance and direction on the interpretation of medical documentation and policies. In addition, this role assists with system programming needs related to medical policy benefits and coding guidelines to ensure claims are being processed in a timely and accurate manner and in accordance to set standards.

Essential Functions
  • Applies clinical knowledge and medical policy principals into medical review processes. Prioritizes duties to ensure timeliness standards and inventory levels of claims are maintained.
  • Reviews professional and institutional claims and corresponding medical records to determine medical necessity and appropriateness of services. Reviews level of care, readmissions and transfers to determine medical necessity and appropriateness and instructs providers on appropriate billing rules which are based on current medical criteria and billing guidelines. Verifies correct coding, billing and level of care are appropriate based on current guidelines and policies, if applicable. Interprets medical polices and determines the most effective and efficient methods of research based on each case. Analyzes clinical data collection from the medical record and provides supportive documentation of outcomes and instructions for claims processing.
  • Provides instruction and documentation of workflow processes to ensure correct claims payment and processing. Communicates, documents and provides clinical rationale when claims need additional review. Analyzes and resolves claims workflow and processing issues and creates, updates and maintains process guidelines and general workflow documents.
  • Utilizes medical knowledge to provide guidance for implementation of system programming related to medical policies, new codes and benefits in relation to the medical review process.
  • Identifies education needs of providers and informs appropriate parties for further review.
  • Works across departments to facilitate the reprocessing of claims, enhance system edits based on case findings and provide education on medical review activities. Addresses medical review questions relating to claims, and medical terminology/language questions. Represents the medical review team on various meetings, workgroups and corporate projects within the organization and serves on committees, as assigned. Collaborates with necessary parties to develop and maintain medical policies and new code system logic related to claims processing for the organization.

Knowledge, Skills and Abilities

Medical Review Expertise


Decision Making




Continuous Learning/Development (Self)



Education Requirements

Required: Associate's

Preferred: Bachelor's

Field(s) of Study: Completion of RN program is required; BSN is highly preferred


Experience Requirements

Required: Minimum of 3 Years

Preferred: Minimum of 5 Years

Experience Details:  Minimum of 3 years of clinical nursing, acute care nursing or related experience is required.


Certification, Licensures & Registration Requirements

Title: North Dakota (ND) Registered Nurse (RN) License or RN License valid for work in ND



State or Agency: Board of Nursing


Equivalent combination of education, experience or training determined to be acceptable by Human Resources may be substituted, unless regulated by contract or program standards

Other Information

Job Posting Policy 6.05

New employees with Blue Cross Blue Shield of North Dakota will be eligible to apply for positions within their assigned department after successfully completing a 90-day review. For positions outside your department, you must attain a minimum of six months of service before you can apply.

Equal Opportunity Employment

Equal Opportunity Employer of Minorities, Females, Protected Veterans and Individual with Disabilities, as well as Sexual Orientation or Gender Identity.

For questions, please email

This job posting will be closed 9/29/2020 at 8:00AM CST. No further applications will be considered.