Job Title: Nurse Chart Reviewer
Location: West Hills/Canoga Park 91305 (This role is HYBRID not remote)
Overview:
The Retro Claims Reviewer is responsible for auditing and reviewing medical claims to ensure accuracy, regulatory compliance, and proper adjudication. This role is ideal for a Licensed Vocational Nurse (LVN) or Registered Nurse (RN) with hands-on experience in Utilization Management (UM) and a strong understanding of HMO/Medicare claims processes.
Key Responsibilities:
• Audit denied provider and member claims for accuracy and compliance
• Review and process claims in accordance with UM guidelines and regulatory standards
• Analyze benefit structures and system configurations (EZCap or similar)
• Collaborate with cross-functional teams to resolve claim issues and process gaps
• Document findings, prepare reports, and present trends to leadership
• Support automated adjudication systems and identify strategies to reduce errors
• Ensure HIPAA ...