Medical Reviewer, Registered Nurse

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

📋 Description

• Analyze and interpret medical records along with clinical documentation to assess the medical necessity and appropriateness of healthcare services.

• Provide clinical review assistance for Treatment Authorization Requests (TARs) and other authorization processes.

• Support medical review functions related to medical policy, claim adjudication, drug utilization review, and various healthcare program requirements.

• Utilize professional nursing principles, clinical judgment, medical policies, and established utilization guidelines while conducting reviews.

• Evaluate documentation to determine if the requested services, procedures, supplies, and equipment meet coverage and clinical standards.

• Accurately and promptly document review findings, decisions, and the supporting clinical rationale.

• Make approval determinations within established guidelines or refer cases to physicians or relevant clinical professionals.

• Utilize knowledge of hospital operations, medical services, medical supplies, and appropriate clinical applications.

• Collaborate effectively with physicians, pharmacists, nurses, and other healthcare professionals.

• Stay updated on clinical criteria, medical policies, procedures, and regulatory standards.

• Adhere to established standards for quality, accuracy, productivity, and turnaround time.

• Primarily work from a home office providing support for Medical Review Services within California healthcare programs.

• Navigate various systems and applications to perform reviews and document findings.

⛳️ Requirements

• A valid and unrestricted Registered Nurse (RN) license to practice in the State of California, in good standing.

• A minimum of two (2) years of professional nursing experience.

• A Master’s Degree in Nursing may substitute for one (1) year of the required professional nursing experience.

• Familiarity with professional nursing principles and techniques, hospital routines, and the uses of medical supplies.

• Training and/or certification in wound and ostomy care is preferred.

• Strong clinical judgment and the ability to interpret medical records and supporting clinical documentation.

• Experience in medical review, utilization review, medical necessity review, prior authorization, Treatment Authorization Requests (TARs), or claims review is preferred.

• Excellent written and verbal communication skills.

• Ability to navigate multiple computer systems and applications.

• Capability to maintain professional licenses, certifications, and credentials in an active, unrestricted, and good-standing status.

🏝️ Benefits

• Flexible hours.

• Work-life balance.

• Continuous learning and career development opportunities.

• Flexible vacation policy.

• 401(k) employer match.

• Comprehensive health benefits.

• Educational assistance.

• Leadership and technical development academies.

• Ongoing training and support.