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Medical Review Rn Jobs in Virginia (NOW HIRING)

Peraton

Medical Review Nurse- Medicare

Reston, VA · On-site

$66K - $106K/yr

Experience in the medical field as a Registered Nurse or other clinician, and/or experience in review of medical claims for coverage and medical necessity. * Current nursing license. Active license ...

Peraton

Medical Review Nurse- Medicare

Herndon, VA · On-site

$66K - $106K/yr

Experience in the medical field as a Registered Nurse or other clinician, and/or experience in review of medical claims for coverage and medical necessity. * Current nursing license. Active license ...

Lifehealth LLC

RN - Nurse Support

Springfield, VA · On-site

$51.77/hr

Review the medical questionnaire following protocols, using medical guidelines and their medical ... Registered professional nurse must possess an unencumbered Registered Nurse license in the State of

LifeHealth

RN - Nurse Support

Springfield, VA · On-site

Review the medical questionnaire following protocols, using medical guidelines and their medical ... Registered professional nurse must possess an unencumbered Registered Nurse license in the State of

LifeHealth

RN - Nurse Support

Springfield, VA · On-site

Review the medical questionnaire following protocols, using medical guidelines and their medical ... Registered professional nurse must possess an unencumbered Registered Nurse license in the State of

GQR Global Markets

RN Case Manager

Charlottesville, VA · On-site

$1.8K - $1.9K/wk

Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location ... Benefits: * Day 1 Insurance * Cigna medical, MetLife dental and vision insurance * License ...

New

GQR

RN - Case Manager

Charlottesville, VA · On-site

$1.8K - $1.9K/wk

Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location ... Benefits: * Day 1 Insurance * Cigna medical, MetLife dental and vision insurance * License ...

GQR Healthcare

Travel Case Manager RN

Charlottesville, VA · On-site

$1.8K - $1.9K/wk

Travel Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location ... Cigna medical, MetLife dental and vision insurance * License reimbursement for new licenses needed ...

Peraton

Nurse Reviewer - Medicaid

Reston, VA · On-site

$66K - $106K/yr

At least 3 years of experience in the medical field as a Registered Nurse or other clinician, and/or experience in review of medical claims for coverage and medical necessity. * Current/Active ...

Peraton

Nurse Reviewer - Medicaid

Herndon, VA · On-site

$66K - $106K/yr

At least 3 years of experience in the medical field as a Registered Nurse or other clinician, and/or experience in review of medical claims for coverage and medical necessity. * Current/Active ...

Peraton

Bilingual Nurse Reviewer - Medicaid

Herndon, VA · On-site

$66K - $106K/yr

At least 3 years of experience in the medical field as a Registered Nurse or other clinician, and/or experience in review of medical claims for coverage and medical necessity. * Current/Active ...

Peraton

Bilingual Nurse Reviewer - Medicaid

Reston, VA · On-site

$66K - $106K/yr

At least 3 years of experience in the medical field as a Registered Nurse or other clinician, and/or experience in review of medical claims for coverage and medical necessity. * Current/Active ...

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All JobsMedical Review Rn JobsMedical Review Rn Jobs in Virginia

Medical Review Rn information

What is a Medical Review RN?

A Medical Review RN is a registered nurse who specializes in reviewing medical records and claims to ensure they meet established guidelines and standards. These nurses often work for insurance companies, government agencies, or healthcare organizations, evaluating the necessity, appropriateness, and efficiency of healthcare services provided to patients. Their role may include determining medical necessity, performing utilization reviews, and supporting appeals or audits. They use their clinical knowledge to interpret complex medical information and collaborate with healthcare providers to support accurate decision-making.

How does a Medical Review RN collaborate with other healthcare professionals during the review process?

A Medical Review RN often works closely with physicians, case managers, and insurance representatives to ensure that medical claims and treatment plans meet regulatory and clinical guidelines. Collaboration may involve participating in interdisciplinary meetings, discussing complex cases, and providing clinical expertise to support utilization management decisions. Effective communication and teamwork are essential, as you'll need to relay findings, request additional information, and sometimes clarify medical necessity with providers. This collaborative environment helps ensure quality care for patients while maintaining compliance with payer policies.

What are the key skills and qualifications needed to thrive as a Medical Review RN, and why are they important?

To thrive as a Medical Review RN, you need a strong clinical background, critical thinking skills, and an active RN license, often supported by experience in case management or utilization review. Familiarity with medical coding, claims management software, and knowledge of regulatory guidelines such as Medicare and Medicaid are typically required. Strong attention to detail, excellent written communication, and the ability to work independently are essential soft skills for this role. These competencies ensure accurate and compliant medical record reviews, which are critical for proper claims adjudication and regulatory adherence.

How to become a medical review RN?

To become a medical review RN, you need to earn a nursing license by completing an accredited nursing program and passing the NCLEX-RN exam. Additionally, gaining experience in clinical settings and obtaining certifications such as Certified Professional Coder (CPC) or specialized training in medical review can enhance qualifications for this role.

What cities in Virginia are hiring for Medical Review Rn jobs?

Cities in Virginia with the most Medical Review Rn job openings:

Medical Review Rn jobs near you
Infographic showing various Medical Review Rn job openings in Virginia as of August 2026, with employment types broken down into 89% Full Time, and 11% Part Time. Highlights an 95% In-person, and 5% Remote job distribution.

Utilization Review Registered Nurse

3M HEALTHCARE

Richmond, VA • On-site

$100 - $125/hr

Other

Posted 5 days ago

Job description

Job Overview

The Utilization Review RN is responsible for utilization management and review for prospective, concurrent, or retrospective cases. The role functions within a multidisciplinary team including physicians, social workers, discharge planning assistants, and payers, evaluating medical appropriateness of inpatient and outpatient services per guidelines and benefit determination.

Responsibilities
  • Conduct prospective, concurrent, and retrospective utilization reviews for inpatient services, observation services, and specific outpatient service requests.
  • Determine medical appropriateness of inpatient and outpatient services by evaluating medical guidelines and benefit determinations.
  • Collaborate with attending and consulting physicians to facilitate efficient transitions during hospitalization.
  • Work with the multidisciplinary team to coordinate care and ensure reimbursement aligns with payer contracts and efficient resource use.
  • Use medical necessity criteria to assess level and setting of care, assist in denial and appeals, evaluate quality, and identify potential risk management issues.
  • Participate in all patient safety initiatives relevant to the position.
  • Maintain professional rapport with providers, patients/families, and internal customers.
  • Train and educate new UM staff nurses and new RN Care Coordinators on job competency and technical instruction.
  • Advocate for appropriate placement of patients to secure correct remuneration.
  • Utilize clinical application systems, utilization review systems, and business support applications.
Qualifications
  • Licensed Registered Nurse in the State of Virginia (or eligible).
  • Current RN licensure in Virginia.
  • Minimum of three (3) years of nursing experience in an acute care setting.
  • Completion of 15 continuing education units per year.
  • Proficiency in Milliman Care Guidelines (MCG) or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
Preferred Experience and Credentials
  • One (1) year of Care Coordination experience.
  • Clinical experience with specialty patient populations.
  • Two (2) to Four (4) years of recent experience in Utilization Review or Utilization Management at a health plan or managed care organization (HMO/TPA/IPA/etc.).
  • Master’s Degree in Nursing or a healthcare-related field from an accredited program.
  • Case Management Certification.
Additional Position Requirements
  • Ability to flex the schedule as needed to meet department demands.
  • Physical lifting capacity of 20-50 lbs.; prolonged sitting; repetitive motion.
  • Strong recall, reasoning, problem solving, hearing, speaking, writing, reading, logical thinking.
  • Ability to handle multiple priorities, frequent customer interactions, and adapt to frequent change.
EEO Statement

EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.

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