*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 and PHI compliance throughout all claim review activities
* Participate in special projects related to claim denials and appeals
*Required Qualifications:*
* Active LVN or RN license (California)
* 2+ years of experience in Utilization Management (UM)
* Hands-on experience with HMO/Medicare claims, audits, and denials
* Familiarity with claims processing systems (EZCap or similar)
* Strong analytical, documentation, and communication skills
* Ability to work independently and prioritize tasks
* Proficiency in MS Office Suite (Excel, Access, PowerPoint, Word)
*Preferred Skills:*
* CPT, HCPCS, ICD-10 coding knowledge
* Advanced Excel skills
* Experience with regulatory agencies and compliance audits
*Job Type & Location*This is a Contract to Hire position based out of Canoga Park, CA 91304.
*Pay and Benefits*The pay range for this position is $35.00 - $50.00/hr.
Eligibility requirements apply to some benefits and may depend on your job
classification and length of employment. Benefits are subject to change and may be
subject to specific elections, plan, or program terms. If eligible, the benefits
available for this temporary role may include the following:
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