June 17, 2026
Remote RN – Medical Claims Reviewer
Mid • Remote
65,000 - 65,000 USD/yr
Nashville, TN
About the Role
We are seeking a dedicated Registered Nurse (RN) to join our Medical Review team. This role involves conducting pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines. The ideal candidate will use their clinical expertise to assess medical necessity, appropriateness, and reimbursement eligibility while documenting decisions in accordance with regulatory and organizational requirements.
Key Responsibilities
- Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
- Assess payment determinations using clinical information and established guidelines.
- Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement.
- Provide clear, well-documented rationales for service approvals or denials.
- Educate internal and external teams on medical review processes, coverage determinations, and coding requirements.
- Support quality control activities to meet corporate and team objectives.
- Provide guidance to LPN team members and support non-clinical staff through training and discussions.
- Assist with special projects and additional responsibilities as assigned.
Minimum Qualifications
- Licensure: Active, unrestricted RN license in the U.S. and in the state of hire OR active compact multistate RN license (Nurse Licensure Compact).
- Education: Associate Degree in Nursing OR graduation from an accredited School of Nursing.
- Experience: Two years of clinical experience plus at least two years in Home Health, Utilization/Medical Review, or Quality Assurance.
- Strong clinical background in managed care, home health, rehabilitation, and/or medical-surgical settings.
- Ability to interpret and apply medical review criteria and clinical guidelines.
- Proficiency in Microsoft Office and word processing software.
- Strong analytical, organizational, and decision-making skills.
- Ability to work independently and manage priorities effectively.
- Ability to handle confidential information with discretion.
Preferred Qualifications
- Three years of clinical nursing experience in Home Health, Utilization Review, Medical Review, or Quality Assurance.
- Proficiency in using multiple screens and software programs simultaneously.
Benefits
- All necessary equipment provided, including desktop computer, dual monitors, headset, ethernet cable, and additional accessories as needed.
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On-site
Indianapolis, IN
🏢 Summary: Home Health Registered Nurse role providing skilled nursing care, patient assessments, care planning, and coordination of services in home settings. The position involves managing patient caseloads, supporting chronic disease management and recovery, and collaborating with interdisciplinary teams. Daily travel within the assigned service area is required. 🗂️ Requirements: Accredited nursing diploma, associate, or bachelor's degree, Current state RN license, Minimum 1 year RN experience in a clinical care setting, Reliable transportation, Valid driver's license, Valid automobile insurance, Willingness to travel daily for home visits, Ability to work independently, Proficiency in OASIS documentation and care planning, Understanding of Medicare, Medicaid, and third-party payor requirements 📃 Skills: RN, OASIS, Medicare, Medicaid, Nursing, Assessment, Careplanning, Documentation 🏢 Description: Optimal Care is where your dedication meets a rewarding career. We are committed to supporting professional growth, valuing clinical expertise, and creating an environment focused on exceptional patient care. As a clinician-owned and operated organization, the focus is on personalized, compassionate care for patients and families. Services include Physician Services, Home Health, and Hospice, supporting chronic disease management, rehabilitation, and end-of-life care. About the Role Practice nursing with the autonomy, time, and patient connection that allows you to make a meaningful impact every day. As a Home Health Registered Nurse, you'll deliver comprehensive skilled nursing care to patients in their homes, supporting recovery, chronic disease management, and overall health goals while helping individuals remain safely in the comfort of their own environment. This role is ideal for an RN who values clinical independence, critical thinking, and building strong relationships with patients and families over time. You'll manage a caseload of patients from admission through discharge, providing skilled nursing care, conducting assessments, and developing individualized care plans tailored to each patient's needs. Working closely with physicians and an interdisciplinary care team, you'll coordinate services, make informed clinical decisions, and play a central role in shaping patient outcomes and supporting each person's journey toward greater health and independence. This role is a high travel position and requires daily travel within the service area to provide care to patients in their homes, assisted living facilities, or nursing homes. Hours Monday to Friday, 8 a.m. to 5 p.m., with weekend rotation. Required Qualifications - Graduate of an accredited Diploma, Associate, or Baccalaureate School of Nursing - Current State License as a Registered Nurse - Minimum 1 year of experience as a licensed RN in a clinical care setting - Reliable transportation, valid driver's license, and valid automobile insurance coverage - Willingness to travel daily for home visits within service area Preferred Qualifications - Bachelor of Science in Nursing (BSN) - Experience in home health environment - OASIS certification or willingness to obtain Essential Skills and Competencies - Strong clinical assessment and critical thinking skills - Proficiency in OASIS documentation and care planning - Excellent time management and organizational abilities - Effective communication and teaching skills - Ability to work independently with minimal supervision - Comfort working in diverse home and facility environments - Strong clinical judgment and decision-making capabilities - Understanding of Medicare, Medicaid, and third-party payor requirements Pay Range $80,000—$87,000 USD How We Care for You - Minimum of 3 Weeks Paid Time Off (PTO) - Medical, Dental, and Vision Insurance - HSA and FSA options including Dependent Care - Company paid Short Term Disability - Company paid Life Insurance - 401(k) with Employer Match - Mileage Reimbursement - Company Vehicle Program for field roles - Pet Insurance - ID and Fraud Protection - And more... Background Screening Employment is contingent upon the successful completion of a background check. Screening is completed by a third-party administrator, the Michigan Long-Term Care Partnership, and is performed in compliance with the Fair Credit Report Act. Reasonable Accommodations Reasonable accommodations are offered throughout the application process, interview stages, and during employment. Equal Opportunity Employer The organization is an equal-opportunity workplace that prohibits discrimination and harassment based on protected characteristics.