Registered Nurse Medical Reviewer

Job Summary

Seeking an experienced Registered Nurse Medical Reviewer, the full-time remote position will manage the medical review of complex claims, pre-authorization requests, appeals, and fraud referrals, applying clinical expertise to determine medical necessity and support accurate payment determinations.

Key Responsibilities:

• Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals
• Assess payment determinations using clinical information and established guidelines
• Provide clear, well-documented rationales for service approvals or denials

Required Qualifications:

• Active, unrestricted RN license in the U.S. or active compact multistate RN license
• Associate Degree in Nursing or graduate of an accredited School of Nursing
• Minimum two years of clinical experience, including at least two years in inpatient/outpatient settings or medical review
• Familiarity with Medicare Part A/B/HHH guidelines
• Strong clinical background in managed care and/or inpatient/outpatient settings