Registered Nurse Claims Analyst

Job Summary

To ensure compliance with healthcare guidelines, the full-time Remote Registered Nurse Claims Analyst will perform medical record and claims reviews for Medicare, Medicaid, and other claims data, assessing for potential overpayment, fraud, waste, and abuse.

Key responsibilities

• Facilitates and manages assigned projects and contracts related to pharmacy services, ensuring contract specifications are met
• Reviews and interprets contract deliverables for timely and accurate completion while contributing to project design and execution
• Provides educational programs and professional presentations to meet project goals and supports changes in care practices

Required qualifications

• 5-7 years of work experience in clinical and utilization review or case management; 8-11 years preferred
• Current, active RN license issued by the state board of nursing
• BSN degree strongly preferred; candidates with an ADN will be considered with equivalent experience
• Coding certification preferred
• Strong analytical skills with the ability to make sound, timely decisions