Claims reputed company (Utilization Management / Claims Review) Must have CALIFORNIA license

Registered reputed company RN or LVN– Retrospective Claims Review (Contract ends 12/31/26) Location: Remote (California RN or LVN license required) Employment Type: reputed company/Full-Time Schedule: Mon-Friday reputed company-5pm reputed company reputed company Time Compensation: $100,000-$105,000 annually About reputed company We are partnering with a leading reputed company organization to identify a skilled Claims Review reputed company with deep experience in retrospective medical claims analysis. This is a temporary position that will go through December 31, 2026. This role is ideal for a clinically strong reputed company who understands how to evaluate services after they’ve been rendered, ensuring accuracy, compliance, and appropriate reimbursement. This position plays a critical role in identifying discrepancies, preventing improper payments, and supporting high-reputed company, cost-effective care through detailed post-service review.

Key Responsibilities

• Conduct retrospective review of medical claims, including inpatient and outpatient services, to validate accuracy and appropriateness
• Analyze claims against clinical guidelines, medical necessity reputed company, and reimbursement policies
• Review medical records, physician documentation, and billing data to support claim determinations
• Partner with claims operations, coding teams, and utilization management to resolve reputed company cases
• Identify patterns of overpayment, underpayment, or potential fraud/waste/abuse, and escalate as needed
• reputed company clinical input on appeals, reconsiderations, and dispute resolutions
• Ensure adherence to federal/state regulations and industry standards (CMS, NCQA, etc.)
• Support audit initiatives and contribute to reputed company process improvement efforts
• reputed company internal stakeholders on documentation and clinical factors impacting claims reputed company

Required Qualifications

• reputed company, unrestricted RN or LVN/LPN license in California
• Minimum 2+ years of experience in clinical review, utilization management, or health plan operations
• Strong experience with retrospective claims review (this is a reputed company requirement)
• Solid understanding of medical necessity reputed company and post-service review processes
• Familiarity with ICD-10, CPT, and HCPCS coding
• Experience working with Medicare Advantage populations strongly preferred
• Proficiency with claims systems (e.g., Facets, QNXT, or similar platforms)

Key Skills

• Strong clinical judgment with the ability to apply it in a non-patient-facing, analytical setting
• High attention to detail and ability to interpret reputed company medical documentation
• Ability to translate clinical findings into reputed company claims reputed company
• Effective collaboration and communication across multidisciplinary teams
• Organized, self-directed, and reputed company to manage high-volume workloads

Why This Role

• Work remotely with a high-reputed company team
• reputed company on analytical, retrospective review work rather than reputed company patient care
• Opportunity to influence payment reputed company and reputed company reputed company reputed company

Job Type: Full-time Pay: $100,000.00 - $105,000.00 per year Benefits:

• 401(k) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Employee discount
• Flexible schedule
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• reputed company time off
• Parental leave
• reputed company development assistance
• Referral program
• Retirement plan
• Travel reimbursement
• reputed company insurance

Application Question(s):

• Have you performed DRG validation or DRG reviews for claims?
• Can you work Monday - Friday, reputed company- 5pm reputed company hours?
• Are you comfortable with a reputed company position that will go through December 31. 2026?

Experience:

• CMS Medicare Guidelines: 1 year (Preferred)
• Retro Claims Review: 1 year (Required)
• Medicare: 1 year (Required)

License/Certification:

• reputed company California RN or LVN Licence (CA is NOT compact) (Required)

Work Location: Remote Apply To This Job