Max Salary: W-2 ($65,000/$31.25)
Location: Remote (U.S. - Work from home)
Remote Work Requirements: High-speed internet (non-satellite) and a private, lockable home office
Equipment: You will be provided with all necessary equipment to perform your job effectively, including but not limited to a desktop computer, dual monitors, a headset, an ethernet cable, and additional accessories as needed.
About the RoleWe are seeking a dedicatedย Registered Nurse (RN)ย to join ourย Medical Review team. This role involves conductingย pre- and post-payment medical reviewsย to ensure compliance with established clinical criteria and guidelines. The ideal candidate will use their clinical expertise to assess medical necessity, appropriateness, and reimbursement eligibility while documenting decisions in accordance with regulatory and organizational requirements.
Key Responsibilities- Reviewย medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
- Assess payment determinations using clinical information and established guidelines.
- Evaluateย medical necessity, appropriateness, and reasonablenessย for coverage and reimbursement.
- Provide clear, well-documented rationales for service approvals or denials.
- Educate internal and external teams onย medical review processes, coverage determinations, and coding requirements.
- Support quality control activities to meet corporate and team objectives.
- Provideย guidance to LPN team membersย and support non-clinical staff through training and discussions.
- Assist withย special projects and additional responsibilitiesย as assigned.
Minimum QualificationsLicensure:- Active, unrestricted RN license in the U.S. and in the state of hire
OR - Activeย compact multistate RN licenseย (as defined by the Nurse Licensure Compact).
Education:- Associate Degree in Nursing
OR - Graduate of an accredited School of Nursing.
Experience:- Two years of clinical experience.
Skills & Competencies:- Strong clinical background inย managed care, home health, rehabilitation, and/or medical-surgical settings.
- Ability to interpret and applyย medical review criteria and clinical guidelines.
- Proficiency inย Microsoft Officeย and word processing software.
- Strongย analytical, organizational, and decision-making skills.
- Ability to work independently while managing priorities effectively.
- Excellentย customer service, communication, and critical thinking skills.
- Ability to handle confidential information with discretion.