Registered Nurse Reviewer

Job Summary

Performing complex medical record reviews for Medicare Part A/B and DMEPOS claims, the full-time Registered Nurse Reviewer will work remotely to assess medical necessity and appropriateness of services while ensuring compliance with established guidelines and policies.

Key Responsibilities

• Conduct detailed medical record reviews requiring clinical judgment on Medicare claims
• Evaluate coverage and medical necessity against national and local policies
• Document rationale for payment or denial recommendations and identify potential fraud indicators

Required Qualifications

• Graduation from an accredited nursing program with current, unrestricted RN licensure
• 2-4 years of clinical experience with a focus on medical necessity and coverage determinations
• Strong knowledge of medical terminology and clinical documentation standards
• Associate's degree or accredited nursing diploma in a healthcare-related field
• Experience in medical/claims review, including pre- and post-payment reviews