State Licensed RN Medical Reviewer

A company is looking for a Remote RN - Medical Claims Reviewer.

Key Responsibilities

Review medically complex claims, pre-authorization requests, appeals, and fraud / abuse referrals

Assess payment determinations using clinical information and established guidelines

Provide clear, well-documented rationales for service approvals or denials

Minimum Qualifications

Active, unrestricted RN license in the U.S. or an active 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 Quality Assurance

Strong clinical background in managed care, home health, rehabilitation, and / or medical-surgical settings

Proficiency in Microsoft Office and word processing software