Remote RN Medical Claims Reviewer

Job Summary

Seeking a dedicated Registered Nurse (RN) for a full-time remote Medical Claims Reviewer position, responsible for conducting pre- and post-payment medical reviews, assessing medical necessity, and documenting compliance with clinical criteria and guidelines.

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 rationales for service approvals or denials and educate teams on medical review processes

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, or medical-surgical settings
• Proficiency in Microsoft Office and ability to interpret medical review criteria