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 established clinical standards and guidelines.

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

• Evaluating payment decisions based on clinical data and prescribed guidelines.

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

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

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

• Assisting in quality control efforts to fulfill corporate and team goals.

• Guiding LPN team members and supporting non-clinical staff through training sessions and discussions.

• Contributing to special projects and taking on additional responsibilities as required.

⛳️ Requirements

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

• 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 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 implement medical review criteria and clinical guidelines.

• Proficiency in Microsoft Office and word processing software.

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

🏝️ Benefits

• Remote work opportunity (U.S. – Work from home).

• High-speed internet connection (non-satellite).

• Private, secure home office space.

• All essential equipment provided.