Remote RN Medical Reviewer

Job Summary

Working remotely, the part-time Remote RN Medical Reviewer will manage a variety of claim types, including Radiology, Ambulance, Physical Therapy, and Surgical, by performing medical reviews using clinical information and established guidelines while documenting decisions and providing support for medical claims.

Key Responsibilities

• Handle various claim types and determine medical necessity, coverage, and payment using clinical information and established criteria
• Review medical claims, including complex services, preauthorization requests, and appeals, while documenting the rationale for payment or denial
• Educate internal and external staff on medical review processes, terminology, and coding, while guiding LPN team members as needed

Required Qualifications

• Active, unrestricted RN license in the U.S. or multistate RN license under the Nurse Licensure Compact
• Associate's degree in nursing or graduation from an accredited nursing program
• Two years of clinical experience plus two years in utilization or medical review, quality assurance, or home health
• Clinical background in home health, rehabilitation, and/or broad medical-surgical experience
• Ability to pass CMS background investigation and complete necessary clearance processes