Medical Reviewer – Medicare, Home Health

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

📋 Description

• Analyze complex medical claims, pre-authorization requests, appeals, and referrals related to fraud and abuse.

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

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

• Deliver clear, well-documented justifications supporting either the approval or denial of services.

• Train internal and external teams on the medical review process, coverage decisions, and coding standards.

• Facilitate quality control initiatives that further corporate and team goals.

• Support special projects and additional tasks as assigned.

⛳️ Requirements

• Valid, unrestricted RN license in the United States and in the state of employment, or an active compact multistate RN license as per the Nurse Licensure Compact.

• Associate Degree in Nursing or graduation from an accredited School of Nursing.

• A minimum of two years of clinical experience along with at least two years in inpatient or outpatient settings, utilization or medical review, or quality assurance.

• Solid clinical background in both managed care and inpatient/outpatient environments.

• Capability to interpret and utilize medical review criteria and clinical guidelines effectively.

• Proficient in Microsoft Office and word processing applications.

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

• Ability to work independently while prioritizing competing tasks.

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

• Competence in managing confidential information with discretion.

• Must successfully pass background checks and drug testing prior to employment; some roles may require fingerprinting.

🏝️ Benefits

• 401(k) plan with company matching.

• Paid Time Off (PTO) that increases with tenure.

• Health, Vision, and Dental insurance.

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

• Short-Term and Long-Term Disability coverage.