Home Health RN – Medical Claims Reviewer

This is a fully remote position, open to applicants in United States.

📋 Description

• Performing pre- and post-payment medical evaluations to ensure adherence to defined clinical criteria and guidelines

• Evaluating medical necessity, appropriateness, and eligibility for reimbursement while documenting decisions

• Analyzing complex medical claims, pre-authorization requests, appeals, and reports of fraud/abuse

• Educating both internal and external teams on medical review procedures, coverage determinations, and coding standards

• Assisting in quality control initiatives to achieve corporate and team goals

• Offering guidance to LPN team members and aiding non-clinical staff through training and discussions

• Supporting special projects and other assigned duties

⛳️ Requirements

• Active, unrestricted RN license in the U.S. and in the state of employment OR Active compact multistate RN license

• Associate Degree in Nursing OR Graduate of an accredited Nursing School

• Minimum of two years of clinical experience, including at least two years in Home Health, Utilization/Medical Review, or Quality Assurance

• Strong clinical expertise in managed care, home health, rehabilitation, and/or medical-surgical environments

• Capability to interpret and apply medical review criteria and clinical guidelines effectively

• Proficient in Microsoft Office and word processing applications

• Excellent analytical, organizational, and decision-making abilities

• Capacity to work independently while effectively managing priorities

• Outstanding customer service, communication, and critical thinking skills

• Ability to manage confidential information with care and discretion.

🏝️ Benefits

• Requirement for high-speed internet

• Requirement for a private, lockable home office

• Provision of necessary equipment including a desktop computer and accessories