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Medical Review Rn Jobs in North Carolina (NOW HIRING)

GQR Global Markets

RN - Case Manager

Burlington, NC · On-site

$1.9K - $2.0K/wk

Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location: Burlington ... Cigna medical, MetLife dental and vision insurance * License reimbursement for new licenses needed ...

GQR

RN - Case Manager

Burlington, NC · On-site

$1.9K - $2.0K/wk

Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location: Burlington ... Benefits: * Day 1 Insurance * Cigna medical, MetLife dental and vision insurance * License ...

Cone Health

RN Utilization Review

Greensboro, NC · On-site

Registered Nurse (RN) 3 Utilization Review A Registered Nurse (RN) 3 Utilization Review monitors and evaluates patient care utilization. Working under minimal supervision, this role manages projects ...

TNAA TotalMed RN

Travel Nurse RN - Med Surg

Bryson City, NC · On-site

$1.6K - $2.2K/wk

TNAA TotalMed RN is seeking a travel nurse RN Med Surg for a travel nursing job in Bryson City, North Carolina. & Requirements * Specialty: Med Surg * Discipline: RN * Duration: 13 weeks * 36 hours ...

TNAA TotalMed RN

Travel Nurse RN - Med Surg

Bryson City, NC · On-site

$1.6K - $2.2K/wk

TNAA TotalMed RN is seeking a travel nurse RN Med Surg for a travel nursing job in Bryson City, North Carolina. & Requirements * Specialty: Med Surg * Discipline: RN * Duration: 13 weeks * 36 hours ...

TNAA TotalMed RN

Travel Med Surg RN

Henderson, NC · On-site

$1.8K - $2.5K/wk

TNAA TotalMed RN is seeking a travel nurse RN Med Surg for a travel nursing job in Henderson, North Carolina. & Requirements * Specialty: Med Surg * Discipline: RN * Duration: 13 weeks * 36 hours per ...

TNAA TotalMed RN

Travel Med Surg RN

Henderson, NC · On-site

$1.8K - $2.5K/wk

TNAA TotalMed RN is seeking a travel nurse RN Med Surg for a travel nursing job in Henderson, North Carolina. & Requirements * Specialty: Med Surg * Discipline: RN * Duration: 13 weeks * 36 hours per ...

TNAA TotalMed RN

Travel Med Surg RN

Rutherfordton, NC · On-site

$1.7K - $2.3K/wk

TNAA TotalMed RN is seeking a travel nurse RN Med Surg for a travel nursing job in Rutherfordton, North Carolina. & Requirements * Specialty: Med Surg * Discipline: RN * Duration: 13 weeks * 36 hours ...

TNAA TotalMed RN

Travel Med Surg RN

Wilmington, NC · On-site

$1.7K - $2.2K/wk

TNAA TotalMed RN is seeking a travel nurse RN Med Surg for a travel nursing job in Wilmington, North Carolina. & Requirements * Specialty: Med Surg * Discipline: RN * Duration: 13 weeks * 48 hours ...

TNAA TotalMed RN

Travel Med Surg RN

Clyde, NC · On-site

$1.7K - $2.3K/wk

TNAA TotalMed RN is seeking a travel nurse RN Med Surg for a travel nursing job in Clyde, North Carolina. & Requirements * Specialty: Med Surg * Discipline: RN * Duration: 13 weeks * 36 hours per ...

TNAA TotalMed RN

Travel Med Surg Tele RN

Wilmington, NC · On-site

$1.7K - $2.2K/wk

TNAA TotalMed RN is seeking a travel nurse RN Med Surg / Telemetry for a travel nursing job in Wilmington, North Carolina. & Requirements * Specialty: Med Surg / Telemetry * Discipline: RN * Duration ...

TNAA TotalMed RN

Travel Med Surg Neuro RN

Wilmington, NC · On-site

$1.7K - $2.2K/wk

TNAA TotalMed RN is seeking a travel nurse RN Med Surg for a travel nursing job in Wilmington, North Carolina. & Requirements * Specialty: Med Surg * Discipline: RN * Duration: 13 weeks * 36 hours ...

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Medical Review Rn information

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 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 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 to become a medical review RN?

To become a medical review RN, you need to earn a nursing license by completing an accredited nursing program and passing the NCLEX-RN exam. Additionally, gaining experience in clinical settings and obtaining certifications such as Certified Professional Coder (CPC) or specialized training in medical review can enhance qualifications for this role.

What cities in North Carolina are hiring for Medical Review Rn jobs?

Cities in North Carolina with the most Medical Review Rn job openings:

Medical Review Rn jobs near you
Infographic showing various Medical Review Rn job openings in North Carolina as of August 2026, with employment types broken down into 1% As Needed, 74% Full Time, 12% Part Time, 7% Temporary, and 6% Contract. Highlights an 89% Physical, 1% Hybrid, and 10% Remote job distribution.

Utilization Review RN Appeals Specialist

CaroMont Health

Gastonia, NC • On-site

Full-time

Re-posted 10 days ago

CaroMont Health rating

6.4

Company rating: 6.4 out of 10

Based on 60 frontline employees who took The Breakroom Quiz

645th of 895 rated healthcare providers

Job description

Job Summary:  The Clinical Appeals Specialist is responsible for managing client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. Where warranted, the Clinical Appeals Nursing Specialist will write sound, compelling factual arguments in order to recoup revenue.  This position also facilitates collaboration between the Utilization Review Specialist's, Medical Staff, Physician Advisor, Nursing staff, Commercial Payers, VA, Managed Medicare Organizations, Medicare, and Medicaid (Center for Medicare/Medicaid Services) to ensure correct admission status as dictated by medical necessity criteria for correct reimbursement for level of care provided and to ensure that any denial is thoroughly reviewed and that an appeal letter, if warranted, is well written and submitted in a timely manner.  In addition, the following are essential duties and responsibilities of the Nurse Reviewer:    Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is warranted.   Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments, where an appeal is warranted.          Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory arguments.   Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable.   Discuss documentation-related, level of care decisions, and clinical issues with physicians and other appropriate staff.   Ensure compliance with HIPAA regulations, to include confidentiality, as required.  Other duties as assigned.   Works closely with the Utilization Review Specialists to ensure that concurrent medical necessity is achieved.  Additionally, works with outside surgical offices when called upon, to provide Medicare Inpatient Only List knowledge to ensure that surgical procedures are correctly called in and billed appropriately.

Qualifications:  Bachelor's degree from an accredited college with a strong clinical background, MSN preferred.  Current state-issued RN license. Minimum of three years experience in clinical area, with project experience and clinical data support preferred. 1 year appeal writing experience is required.   Knowledge in areas such as InterQual Level of Care Criteria as well as knowledge of third party payer regulations related to utilization and quality review is also preferred.    Must have excellent oral communication and organizational skills. Must have excellent writing skills. Previous experience with clinical resource utilization analysis, auditing, appeal writing, and chart review. Knowledge of state and federal regulations in regard to Medicare and Quality Management activities is a must.  . Certification is required within one year of hire.

EOE AA M/F/Vet/Disability

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