Registered Nurse Medical Reviewer

Job Summary

To support Medicare medical review operations, the full-time Registered Nurse Medical Reviewer will supervise a team of approximately 20 RN Medical Reviewers, manage daily workload distribution, ensure compliance with CMS requirements, and serve as the first line of escalation for case risk and provider concerns while working remotely.

Key Responsibilities

• Directly supervise a team of RN Medical Reviewers, managing case assignments and workload distribution
• Monitor case turnaround against the 7-business-day requirement, identifying and addressing potential bottlenecks
• Conduct virtual desk audits to ensure compliance with CMS security requirements and mentor newly onboarded reviewers

Required Qualifications

• Active, unrestricted RN license (single-state or compact multistate)
• ADN or accredited nursing degree (BSN preferred)
• 10+ years of nursing experience, including 4+ years in Medicare medical review or utilization review
• Strong documentation and independent decision-making skills
• Must reside and work from within the U.S., D.C., or a U.S. territory with a secure home workspace