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Insurance Claim Review Nurse Jobs (NOW HIRING)

Ampcus

Clinical Medical Review Nurse

Baltimore, MD · On-site

The incumbent will handle pre and post claim medical review for Commercial, FEP and Medicare ... nursing clinical judgment and corporate/medical policies for claims processing and/or adjudication ...

Integrated Resources

Care Review Nurse

Columbus, OH · On-site

Insurance Utilization Manager/Review and Millemen Experience (MCG). No case managers if that is ... Nurses who are used to doing both production and review work All your information will be kept ...

Church Mutual Insurance, S.I.

Claim Processor

Merrill, WI · On-site

$18.50 - $23.25/hr

Verify coverage and determine our obligation(s) to the insured and/or claimant. * Review claims to determine type of claim presented, claim documentation/evidence presented, amount of claim, or ...

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Insurance Claim Review Nurse information

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How much do insurance claim review nurse jobs pay per hour?

As of Sep 9, 2026, the average hourly pay for insurance claim review nurse in the United States is $23.50, according to ZipRecruiter salary data. Most workers in this role earn between $17.55 and $25.72 per hour, depending on experience, location, and employer.

What does an insurance claim review nurse do?

An Insurance Claim Review Nurse is a registered nurse who evaluates medical claims submitted to insurance companies. They review patient records, treatment plans, and billing codes to ensure that the services provided are medically necessary and covered under the patient’s insurance policy. Their role helps prevent fraud, control costs, and ensure that claims are processed accurately and efficiently. They may also communicate with healthcare providers and policyholders to gather additional information or clarify details about the claims.

What skills and qualifications are needed to be an insurance claim review nurse?

To thrive as an Insurance Claim Review Nurse, you need clinical expertise, a nursing degree with active RN licensure, and experience in utilization review or case management. Familiarity with claims processing systems, ICD-10/CPT coding, and health insurance regulations is essential, and certification such as CCM or URAC accreditation can be advantageous. Analytical thinking, attention to detail, and effective written communication are crucial soft skills for reviewing claims and collaborating with providers. These skills ensure accurate, efficient claim assessments and support compliance with industry standards, reducing errors and unnecessary costs.

What challenges does an insurance claim review nurse face when evaluating claims?

Insurance Claim Review Nurses often encounter complex cases requiring careful assessment of medical records, treatment plans, and insurance policies. A common challenge is ensuring compliance with both regulatory standards and the insurer’s guidelines while maintaining timely turnaround on reviews. Balancing thoroughness with productivity can be demanding, especially when navigating ambiguous documentation or conflicting medical opinions. Effective communication with physicians, claims adjusters, and policyholders is essential to resolve discrepancies and ensure fair claim outcomes.

What is the difference between Insurance Claim Review Nurse vs Insurance Claims Adjuster?

AspectInsurance Claim Review NurseInsurance Claims Adjuster
Required CredentialsRN license, possibly certifications in case management or reviewAdjuster license, certifications like AIC or CPCU
Work EnvironmentHealthcare settings, insurance companies, remote reviewField or office-based, investigating and settling claims
Industry UsageHealth insurance, workers' compensationProperty, casualty, health insurance

Both roles involve evaluating insurance claims, but the Insurance Claim Review Nurse focuses on health-related claims with medical expertise, while the Insurance Claims Adjuster handles a broader range of insurance types, often involving investigation and settlement processes.

What are popular job titles related to Insurance Claim Review Nurse jobs?

For Insurance Claim Review Nurse jobs, the most frequently searched job titles are:

Infographic showing various Insurance Claim Review Nurse job openings in the United States as of September 2026, with employment types broken down into 1% As Needed, 73% Full Time, 21% Part Time, and 5% Contract. Highlights an 89% Physical, 1% Hybrid, and 10% Remote job distribution, with an average salary of $48,885 per year, or $23.5 per hour.

UTILIZATION REVIEW NURSE

Norfolk, VA • On-site

Sentara Health Plans
See more jobs at Sentara Health Plansexternal

$10K/mo

Other

Medical, Dental, Vision, Life, Retirement, PTO

Posted 8 days ago

Key responsibilities

  • Conduct utilization management services including prior authorization, retrospective review, and medical director referrals.

  • Review provider requests for services requiring authorization and conduct pre-certification and care coordination to ensure treatment appropriateness.

  • Provide written and/or verbal notification to members and providers regarding approval or denial decisions.

Job description

City/State Norfolk, VA Work Shift First (Days) Overview: Sentara Health Plans Community Care is looking to hire a Utilization Review Nurse. The Utilization Review Nurse is responsible for utilization management services within the scope of licensure. Conducts primary functions of prior authorization, retrospective review, medical director referrals and execution of member/provider approval and/or denial letter. Reviews provider requests for services requiring authorization. Conducts pre-certification, care coordination for appropriateness of treatment, set reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Responsible for written and/or verbal notification to members and providers. Ensures medical director written decision is consistent with criteria (CMS, state, medical policy, clinical criteria). Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

Education
  • BSN (preferred)
Certification
  • Registered Nurse (required)
Experience
  • 3 years of acute care clinical experience (required)
  • Previous Utilization Review experience (preferred)
  • Milliman experience (preferred)
  • Knowledge of NCQA (preferred)
  • Microsoft suite (Word, Excel, Outlook) (preferred)
Keywords

Talroo- Health, Utilization Review Nurse, RN, Care Coordination, or Discharge Planning, Case Management, Milliman, NCQA

Benefits

Caring For Your Family and Your Career

  • Medical, Dental, Vision plans
  • Adoption, Fertility and Surrogacy Reimbursement up to $10,000
  • Paid Time Off and Sick Leave
  • Paid Parental & Family Caregiver Leave
  • Emergency Backup Care
  • Long-Term, Short-Term Disability, and Critical Illness plans
  • Life Insurance
  • 401k/403B with Employer Match
  • Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education
  • Student Debt Pay Down – $10,000
  • Pet Insurance
  • Legal Resources Plan

Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.

Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

In support of our mission “to improve health every day,” this is a tobacco-free environment. For positions that are available as remote work, Sentara Health employs associates in the following states: Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.

Sentara Health is a Virginia and Northeastern North Carolina based not-for-profit integrated healthcare provider that has been in business for over 131 years. Offering hundreds of sites of care including 12 hospitals, PACE, home health, hospice, medical groups, imaging services, therapy, outpatient surgery centers, and an 858,000 member health plan.

The people of the communities that we serve have nominated Sentara “Employer of Choice” for over ten years. U.S. News and World Report has recognized Sentara as having the Best Hospitals for 15+ years. Sentara offers professional development and a continued employment philosophy!

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