Remote RN – Medical Claims Reviewer

of clinical experience

Inpatient/Outpatient settings (i.e.

Utilization/Medical Review

of clinical nursing experience in

Inpatient/Outpatient settings, Utilization Review, Medical Review, or Quality Assurance

Proficiency in using multiple screens and software programs simultaneously.

pre- and post-payment medical reviews

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.

medically complex claims

, pre-authorization requests, appeals, and fraud/abuse referrals.

Assess payment determinations using clinical information and established guidelines.