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Medical Review Rn Jobs in Alabama (NOW HIRING)

Birmingham

Quality Review Coordinator

Birmingham, AL · On-site

BASIC FUNCTION Perform and administer level 2 Medical Review Pre-Determinations according to ... Registration (RN) from the state. The incumbent must know claims payment guidelines, billing ...

Baldwin Health

Medsurg RN

Foley, AL

Participates in audits, chart reviews, and compliance checks to ensure adherence to standards of ... Endoscopy RN: * Assesses patient needs, reviews medical history, explains procedures, obtains ...

Community Health Systems

Medsurg RN

Foley, AL

Participates in audits, chart reviews, and compliance checks to ensure adherence to standards of ... Endoscopy RN: * Assesses patient needs, reviews medical history, explains procedures, obtains ...

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What are the key skills and qualifications needed to thrive as a Medical Review RN, and why are they important?

To thrive as a Medical Review RN, you need a strong clinical background, critical thinking skills, and an active RN license, often supported by experience in case management or utilization review. Familiarity with medical coding, claims management software, and knowledge of regulatory guidelines such as Medicare and Medicaid are typically required. Strong attention to detail, excellent written communication, and the ability to work independently are essential soft skills for this role. These competencies ensure accurate and compliant medical record reviews, which are critical for proper claims adjudication and regulatory adherence.

How does a Medical Review RN collaborate with other healthcare professionals during the review process?

A Medical Review RN often works closely with physicians, case managers, and insurance representatives to ensure that medical claims and treatment plans meet regulatory and clinical guidelines. Collaboration may involve participating in interdisciplinary meetings, discussing complex cases, and providing clinical expertise to support utilization management decisions. Effective communication and teamwork are essential, as you'll need to relay findings, request additional information, and sometimes clarify medical necessity with providers. This collaborative environment helps ensure quality care for patients while maintaining compliance with payer policies.

What is a Medical Review RN?

A Medical Review RN is a registered nurse who specializes in reviewing medical records and claims to ensure they meet established guidelines and standards. These nurses often work for insurance companies, government agencies, or healthcare organizations, evaluating the necessity, appropriateness, and efficiency of healthcare services provided to patients. Their role may include determining medical necessity, performing utilization reviews, and supporting appeals or audits. They use their clinical knowledge to interpret complex medical information and collaborate with healthcare providers to support accurate decision-making.

How to become a medical review nurse?

To become a medical review nurse, one must typically earn a nursing license by completing an accredited nursing program and passing the NCLEX-RN exam. Experience in clinical nursing and knowledge of medical coding, documentation, and healthcare regulations are also important, and some roles may require certification in case management or utilization review.
What are popular job titles related to Medical Review Rn jobs in Alabama? For Medical Review Rn jobs in Alabama, the most frequently searched job titles are:
What job categories do people searching Medical Review Rn jobs in Alabama look for? The top searched job categories for Medical Review Rn jobs in Alabama are:
What cities in Alabama are hiring for Medical Review Rn jobs? Cities in Alabama with the most Medical Review Rn job openings:
Medical Review Rn jobs near you
Infographic showing various Medical Review Rn job openings in Alabama as of May 2026, with employment types broken down into 1% As Needed, 87% Full Time, 6% Part Time, and 6% Contract. Highlights an 100% Physical job distribution.

Quality Review Coordinator

Birmingham

Birmingham, AL • On-site

Full-time

Posted 29 days ago

Job description

BASIC FUNCTION
Perform and administer level 2 Medical Review Pre-Determinations according to benefit language and standard medical care.
ENVIRONMENT
The Health Managed Department is responsible for developing, implementing and administering private business and government utilization review, medical review, cost containment, reconsiderations, and post payment audit programs to assure optimization of cost savings to the company regarding medical claims. The Medical Review Unit develops, implements, and administers programs such as Medical Review and Preferred Medical Doctor, to determine medical necessity of services and impact cost savings.
WORKFLOW
Work is received via fax or mail from providers, groups and subscribers. Incumbent performs reviews of proposed procedures to approve reimbursement or denial of services. Incumbent performs special projects to investigate propriety of PMD and claims and assures PMD guidelines are followed. Incumbent provides weekly reports on request activities. Incumbent prepares reconsideration case for Level III review. The incumbent creates allow or reject on each contract for which a decision has been rendered. The incumbent researches and suggests changes to guides according to the most recent scientific literature.
KNOWLEDGE
Incumbent must have a thorough understanding of medical practice that can be obtained through a nursing degree program or experience required to obtain Registration (RN) from the state. The incumbent must know claims payment guidelines, billing guidelines, laws and contracts that govern the health insurance program administered by this corporation. The incumbent must be able to discuss coverage guidelines and benefit issues with physicians, group administrators, or internal customers. The incumbent must be able to assist groups in benefit design within the parameters of cost and standard medical care.
THINKING REQUIREMENTS:
The incumbent must be an independent thinker and therefore able to work closely via personal, written or oral communication with representatives and officials of public, private and governmental agencies and professionals inside and outside the Corporation. These groups include the provider financial and medical representatives, customer representatives, and Blue Cross and Blue Shield representatives.
INTERFACES AND INTERPERSONAL SKILLS:
Incumbent has contact with groups, providers and their office representatives, subscribers and internal departments involved with Marketing and claims processing. This contact is usually one to one. However, it can be in the form of a presentation to large audiences. Frequently, the provider or subscriber is frustrated and angry and incumbent must be able to establish effective communications to resolve problems.
AUTHORITY AND DECISION MAKING:
Incumbent decides medical necessity of particular procedure in accordance to contract limits and standard medical practice, and resolves problems for subscribers, groups and providers. Incumbent represents Blue Cross and Blue Shield of Alabama when performing before a large group.
PRINCIPAL ACCOUNTABLITIES
  • Activity: Perform medical and utilization predeterminations of PMD and/or non-PMD providers both in state and out.
    End Result: To determine if coding is correct and procedures filed were medically necessary in order to control and reduce medical care costs
  • Activity: Respond to telephone or written requests for information from Subscribers and providers.
    End Result: To provide requested information to solve claims problems
  • Activity: Perform special projects with requested guidelines
    End Result: To investigate costs associated with PMD to assure compliance with PMD guidelines
  • Activity: Prepare dialogue and support materials for workshops thorugh the state, as directed, for groups, agencies or providers.
    End Result: To educate groups, providers, and subscribers in total program concepts
  • Activity: Assist in the development of new preferred care programs and their guidelines.
    End Result: To expand health management products, control costs and reduce overall medical expenses

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