Medical Reviewer

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

📋 Description

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

• Evaluate payment decisions utilizing clinical data and established criteria.

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

• Deliver clear, well-supported rationales for approvals or denials of services.

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

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

• 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 defined by the Nurse Licensure Compact).

• Associate Degree in Nursing OR a graduate of an accredited School of Nursing.

• A minimum of two years of clinical experience along with at least two years in one of the following areas: inpatient/outpatient settings; utilization/medical review; intensive care (ICU/ER); quality assurance.

• Knowledge of Medicare Part A/B/HHH guidelines.

• Strong clinical experience in managed care and/or inpatient/outpatient environments.

• Capability to interpret and apply medical review standards and clinical guidelines.

• Proficiency in Microsoft Office and word processing applications.

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

• Capacity to work independently while effectively managing priorities.

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

• Ability to manage confidential information with care.

• Must have resided in the United States for at least 3 out of the last 5 years to successfully pass the required background check.

• Private home office equipped with high-speed, hardwired internet connection.

• Fiber internet; 5G satellite home internet is not acceptable.

• Must successfully complete a background check and drug screening prior to commencement; some positions may necessitate fingerprinting.

🏝️ Benefits

• 401(k) plan with company matching.

• Paid time off that increases with tenure.

• Health, Vision, and Dental insurance.

• Company-provided Life Insurance and optional Voluntary Life Insurance.

• Short Term and Long Term Disability coverage.

• Reasonable accommodations available for applicants with disabilities.