Medical Claim Reviewer, CGS, DMEC

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

📋 Description

• Analyze complex medical claims, pre-authorization requests, appeals, and reports of fraud or abuse.

• Evaluate payment decisions based on clinical data and established protocols.

• Determine the medical necessity, appropriateness, and reasonableness for coverage and reimbursement.

• Offer clear and well-documented justifications for service approvals or denials.

• Educate both internal and external teams regarding medical review processes, coverage decisions, and coding standards.

• Assist in quality control initiatives to achieve corporate and team goals.

• Provide support and guidance to LPN team members and aid non-clinical staff through training and discussions.

• Contribute to special projects and undertake additional responsibilities as needed.

⛳️ Requirements

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

• Active compact multistate RN license (as specified by the Nurse Licensure Compact).

• Associate Degree in Nursing OR

• Graduation from an accredited School of Nursing.

• Minimum of two years of clinical experience.

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

• Capability to interpret and implement medical review criteria and clinical guidelines.

• Proficient in Microsoft Office and word processing applications.

• Excellent analytical, organizational, and decision-making abilities.

• Outstanding customer service, communication, and critical thinking skills.

• Ability to manage confidential information with care.

🏝️ Benefits

• Health insurance

• 401(k) matching

• Flexible work arrangements

• Professional development opportunities

• Equipment provided for work