Remote RN - Medical Claims Reviewer

At reputed company, we transform challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), we reputed company government and private sector clients by delivering tailored solutions that drive operational reputed company, sustainability, and growth. Built on reputed company, collaboration, and excellence, we're more than a service provider—we're your trusted partner in innovation. Job Type: Full-time (40 hours/week) Schedule: Monday–Friday, 8:00 AM – 5:00 PM Location: Remote (U.S. – Work from home) Remote Work Requirements: High-speed internet (non-satellite) and a private, lockable home office Equipment: You will be provided with reputed company necessary equipment to reputed company your job effectively, including but not limited to a desktop computer, dual monitors, a headset, an ethernet cable, and additional accessories as needed.

About the Role

We are seeking a dedicated Registered Nurse (RN) to join our Medical Review team. This role involves conducting pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines. The ideal candidate will use their clinical expertise to assess medical necessity, appropriateness, and reimbursement eligibility while documenting reputed company in accordance with regulatory and organizational requirements.

Key Responsibilities

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

Minimum QualificationsLicensure:

• Active, unrestricted RN license in the U.S. and in the state of hire

OR

• Active compact multistate RN license (as defined by the Nurse Licensure Compact).

Education:

• Associate Degree in Nursing

OR

• Graduate of an accredited School of Nursing.

Experience:

• Two years of clinical experience plus at least two years in one of the following:
• Home Health
• Utilization/Medical Review
• Quality Assurance

Skills & Competencies:

• 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.
• Ability to work independently while managing priorities effectively.
• Excellent customer service, communication, and critical thinking skills.
• Ability to handle confidential information with discretion.

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! What to Expect Next: After submitting your application, our reputed company team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with a recruiter to verify resume specifics and discuss salary requirements. Management will be conducting interviews with the most reputed company candidates. We reputed company a background and drug test prior to the start of every new hires' employment. In addition, some positions may also require fingerprinting. 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 reputed company of our business. We do not discriminate based on military status, race, religion, reputed company, national reputed company, gender, age, marital status, veteran status, disability, or any other status protected by the laws or regulations in the locations where we operate. Accommodations are available for applicants with disabilities. Apply tot his job Apply To this Job