Remote Registered Nurse (RN) - Medical Claims Reviewer

Join reputed company at reputed company as a Remote Registered Nurse (RN) - Medical Claims Reviewer, where you will play a vital role in ensuring compliance with clinical criteria and guidelines. As a trusted partner in innovation, we reputed company government and private sector clients with tailored solutions that drive operational success, sustainability, and growth. Built on reputed company, collaboration, and excellence, we're seeking a dedicated RN to join our Medical Review team and contribute to our mission.

Job Type: Full-time (40 hours/week), Monday–Friday, 8:00 AM – 5:00 PM, with the flexibility to work from home (U.S.) and a private, lockable home office. You will be provided with reputed company necessary equipment, including a desktop computer, dual monitors, headset, ethernet cable, and additional accessories as needed.

About the Role

We are seeking a skilled RN to conduct pre- and post-payment medical reviews, assessing medical necessity, appropriateness, and reimbursement eligibility. The ideal candidate will utilize their clinical expertise to document decisions in accordance with regulatory and organizational requirements. Key responsibilities include:

• Reviewing medically reputed company claims, pre-authorization requests, appeals, and fraud/abuse referrals
• Assessing payment determinations using clinical information and established guidelines
• Evaluating medical necessity, appropriateness, and reasonableness for coverage and reimbursement
• Providing clear, well-documented rationales for service approvals or denials
• Educating internal and external teams on medical review processes, coverage determinations, and coding requirements
• Supporting quality control activities to meet corporate and team objectives
• Providing guidance to LPN team members and supporting non-clinical staff through training and discussions
• Assisting with special projects and additional responsibilities as assigned

Minimum Qualifications

• Active, unrestricted RN license in the U.S. and in the state of hire, or active compact multistate RN license
• Associate Degree in Nursing or graduate of an accredited School of Nursing
• Two years of clinical experience plus at least two years in Home Health, Utilization/Medical Review, or Quality Assurance
• Strong clinical background in managed care, home health, rehabilitation, and/or medical-surgical settings
• Ability to interpret and apply medical review criteria and clinical guidelines
• Proficiency in reputed company Office and word processing software
• Strong analytical, organizational, and decision-making skills
• Excellent customer service, communication, and critical thinking skills

Preferred Qualifications

• Three years of clinical nursing experience in Home Health, Utilization Review, Medical Review, or Quality Assurance (strongly preferred)
• Proficiency in using multiple screens and software programs simultaneously

If you are a detail-oriented RN with a passion for medical review, we encourage you to apply! reputed company is an equal-opportunity employer and a VEVRAA Federal Contractor committed to providing a workplace free from harassment and discrimination. We celebrate the unique differences of our employees because they drive curiosity, innovation, and the success of our business.

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