Virginia Licensed Nurse Reviewer

Job Summary

To support healthcare quality assurance, the full-time Sr. Nurse Reviewer (Medicare) will perform complex medical record reviews of Medicare claims remotely, utilizing clinical judgment to assess overpayment potential and compliance with established guidelines.

Key Responsibilities

• Perform complex medical record reviews requiring clinical judgment on Medicare Part A/B and DMEPOS claims
• Determine coverage, medical necessity, and appropriateness of services against NCDs, LCDs, and CMS coverage/payment policy
• Document clear, defensible rationale for payment or denial recommendations

Required Qualifications

• Graduation from an accredited school of nursing with current, unrestricted licensure as a Registered Nurse (RN)
• 2-4 years of clinical experience with demonstrated ability to apply clinical judgment to medical necessity and coverage determinations
• Detail-oriented with strong knowledge of medical terminology and clinical documentation standards
• Associate's degree (or accredited nursing diploma) in a healthcare-related field
• Experience in medical/claims review, including pre- and post-payment claims reviews