RN Medical Reviewer

Job Summary

Working remotely in a full-time capacity, the RN Medical Reviewer will perform medical reviews of claims, determine medical necessity, and document decisions based on clinical guidelines while supporting utilization practices.

Key responsibilities

• Conduct medical claim reviews for complex services and preauthorization requests
• Make payment determinations based on clinical information and established criteria
• Educate internal and external staff on medical reviews and coding procedures

Required qualifications

• Associate's degree in a job-related field or graduate of an accredited School of Nursing
• Active RN licensure in the state hired or an active compact multistate RN license
• At least 2 years of clinical experience
• Proficient in Microsoft Office and word processing software
• Ability to work independently and handle confidential information with discretion