Remote RN – Medical Claims Reviewer

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.