RN Clinical Medical Review Nurse

Job Summary

Working remotely with occasional in-office meetings, the full-time RN Clinical Medical Review Nurse will manage the review of professional and institutional claims, determine eligibility for benefits, and support claims processing while utilizing clinical judgment and nursing expertise.

Key responsibilities

• Research and analyze claims using critical thinking and nursing clinical judgment for claims processing and adjudication
• Perform high-level research on medical policies and assess their impact on claims
• Participate in medical policy meetings and collaborate with medical directors on special projects

Required qualifications

• High School Diploma or GED
• RN - Registered Nurse - State Licensure and/or Compact State Licensure in VA, DC, or MD
• 3 years of acute clinical experience, including case management or utilization review
• Preferred: Bachelor's degree in Nursing