Registered Nurse Medical Reviewer

Job Summary

To support the review of complex Medicare claims, the full-time Remote Registered Nurse Medical Reviewer will evaluate pre-authorization requests, appeals, and fraud referrals, applying clinical expertise to ensure accurate payment determinations.

Key responsibilities

• Review medically complex claims, pre-authorization requests, appeals, and fraud and abuse referrals
• Assess payment determinations using clinical information and established guidelines
• Provide clear, well-documented rationales supporting approval or denial of services

Required qualifications

• Active, unrestricted RN license in the United States 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 inpatient or outpatient settings, utilization or medical review, or quality assurance