Senior Nurse Reviewer

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

📋 Description

• Conduct thorough evaluations of medical claims utilizing UB-04 forms along with detailed itemized statements.

• Confirm itemized charges in accordance with client policies and industry standards.

• Perform level-of-care and utilization reviews by assessing medical records against established criteria.

• Ascertain whether the documentation in medical records justifies the necessity for services.

• Uphold production goals and maintain quality standards.

• Support management in training new reviewers through monitoring, mentoring, providing feedback, and education.

• Stay updated on clinical and coding guidelines while fulfilling required continuing education units (CEUs).

• Participate in training sessions and scheduled meetings.

• Engage in cross-training to review various claim types.

• Collaborate with teams and departments during standard business hours.

• Travel as necessary to meet business requirements.

⛳️ Requirements

• Possess an active, unrestricted RN license from the United States or an active compact multistate unrestricted RN license under the Nurse Licensure Compact (NLC) in the primary state of residence.

• Have a minimum of 5 years of clinical experience within an inpatient hospital environment.

• At least 1 year of experience in itemized bill review is required.

• Preferably 3 years of experience in utilization review or claims auditing.

• Familiarity with CPT, ICD-10, and HCPCS coding guidelines is essential.

• Experience with MCG or InterQual criteria is preferred.

• Demonstrated ability to manage multiple tasks in a high-paced production environment.

• Must be based within the continental United States.

• Access to high-speed internet and a distraction-free work environment is necessary.

• Availability to work during standard business hours is required.

• Willingness to attend training sessions and scheduled meetings.

• Ability to travel at least 10% of the time if business needs arise.

🏝️ Benefits

• Flexible hours.

• Work-life balance.

• Continuous learning and career development opportunities.

• Flexible vacation policy.

• 401(k) employer matching.

• Comprehensive health benefits.

• Educational assistance.

• Leadership and technical development academies.