Remote RN Medical Claims Reviewer

Job Summary

A company is looking for a Remote RN - Medical Claims Reviewer.

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
• Two years of clinical experience plus at least two years in Home Health, Utilization/Medical Review, or Quality Assurance
• Strong clinical background in managed care, home health, rehabilitation, and/or medical-surgical settings
• Proficiency in Microsoft Office and word processing software