Remote RN – Medical Claims Reviewer

Overview

As a Remote RN – Medical Claims Reviewer, you will be part of a team that conducts medical reviews to ensure compliance with clinical criteria and guidelines.

In Short

• Conduct pre- and post-payment medical reviews.
• Assess medical necessity and reimbursement eligibility.
• Document decisions according to regulatory requirements.
• Review complex claims and pre-authorization requests.
• Provide rationales for service approvals or denials.
• Educate teams on medical review processes.
• Support quality control activities.
• Assist with special projects as needed.
• Work from home with necessary equipment provided.
• Full-time position with a Monday to Friday schedule.

Requirements

• Active RN license in the U.S.
• Associate Degree in Nursing or equivalent.
• Two years of clinical experience.
• Experience in medical review or quality assurance preferred.
• Strong clinical background in managed care.
• Ability to interpret medical review criteria.
• Proficiency in Microsoft Office.
• Excellent communication and critical thinking skills.
• Ability to handle confidential information.
• Independent work with effective priority management.

Benefits

• Work from home flexibility.
• Provided equipment for job performance.
• Opportunities for professional growth.
• Supportive work environment.
• Competitive salary.