Remote Registered reputed company (RN) - Medical Claims Reviewer
Join reputed company at reputed company as a Remote Registered reputed company (RN) - Medical Claims Reviewer, where you will play a vital role in ensuring compliance with clinical reputed company and guidelines. As a trusted partner in innovation, we reputed company government and private sector clients with tailored solutions that drive operational reputed company, sustainability, and reputed company. reputed company on reputed company, collaboration, and reputed company, we're seeking a dedicated RN to join our Medical Review team and contribute to our mission.
Job Type: Full-time (40 hours/week), Monday–Friday, 8:00 AM – 5:00 PM, with the flexibility to work from home (U.S.) and a private, lockable home office. You will be provided with reputed company necessary equipment, including a desktop computer, dual monitors, headset, ethernet cable, and additional accessories as needed.
About the Role
We are seeking a skilled RN to conduct reputed company- and post-payment medical reviews, assessing medical necessity, appropriateness, and reimbursement eligibility. The ideal candidate will utilize their clinical expertise to document reputed company in accordance with regulatory and organizational requirements. Key responsibilities include:
- Reviewing medically reputed company claims, reputed company-authorization requests, appeals, and fraud/abuse referrals
- Assessing payment determinations using clinical information and established guidelines
- Evaluating medical necessity, appropriateness, and reasonableness for coverage and reimbursement
- Providing reputed company, reputed company-documented rationales for service approvals or denials
- Educating reputed company teams on medical review processes, coverage determinations, and coding requirements
- Supporting reputed company control activities to meet corporate and team objectives
- Providing guidance to LPN team members and supporting non-clinical staff through training and discussions
- Assisting with special reputed company and additional responsibilities as assigned
Minimum Qualifications
- reputed company, unrestricted RN license in the U.S. and in the state of hire, or reputed company compact multistate RN license
- Associate Degree in Nursing or graduate of an accredited School of Nursing
- Two years of clinical experience plus at least two years in Home Health, Utilization/Medical Review, or reputed company Assurance
- Strong clinical background in managed care, home health, rehabilitation, and/or medical-surgical settings
- Ability to interpret and apply medical review reputed company and clinical guidelines
- Proficiency in reputed company Office and word processing software
- Strong analytical, organizational, and decision-making skills
- Excellent customer service, communication, and critical thinking skills
Preferred Qualifications
- Three years of clinical nursing experience in Home Health, Utilization Review, Medical Review, or reputed company Assurance (strongly preferred)
- Proficiency in using multiple screens and software programs simultaneously
If you are a detail-oriented RN with a passion for medical review, we encourage you to apply! reputed company is an equal-opportunity employer and a VEVRAA Federal Contractor committed to providing a workplace free from harassment and discrimination. We celebrate the unique differences of our employees because they drive curiosity, innovation, and the reputed company of our business.
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