Remote Medical Reviewer (Medicare- Home Health)

Position summary

We are seeking an experienced Registered Nurse to perform medical review of complex claims, pre-authorization requests, appeals, and fraud and abuse referrals. In this role you will apply clinical expertise and established coverage guidelines to determine medical necessity and support accurate payment determinations.

Key responsibilities

• Review medically complex claims, pre-authorization requests, appeals, and fraud and abuse referrals
• Assess payment determinations using clinical information and established guidelines
• Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement
• Provide clear, well-documented rationales supporting approval or denial of services
• Educate internal and external teams on medical review processes, coverage determinations, and coding requirements
• Support quality control activities that advance corporate and team objectives
• Assist with special projects and additional duties as assigned

Minimum qualifications

Licensure

• Active, unrestricted RN license in the United States and in the state of hire, or
• Active compact multistate RN license 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, plus at least two years in one of the following:

  • Inpatient or outpatient settings (for example, medical-surgical, rehabilitation, skilled nursing facility)
  • Utilization or medical review
  • Quality assurance