Medical Reviewer (Remote)

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/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 for service approvals or denials.
• Educate internal and external teams on medical review processes, coverage determinations, and coding requirements.
• Support quality control activities to meet corporate and team objectives. Assist with special projects and additional responsibilities as assigned.

Minimum Qualifications:

Licensure:

• Active, unrestricted RN license in the U.S. 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:

• Minimum two years of clinical experience plus at least two years in one of the following:
  • Inpatient/Outpatient settings (i.e. medical-surgical, rehabilitation, SNF, etc.)
  • Utilization/Medical Review Intensive care (ICU/ER)
  • Quality Assurance Familiarity with Medicare Part A/B/HHH guidelines

Skills & Competencies:

• Strong clinical background in managed care and/or inpatient/outpatient settings.
• Ability to interpret and apply medical review criteria and clinical guidelines.
• Proficiency in Microsoft Office and word processing software.
• Strong analytical, organizational, and decision-making skills.
• Ability to work independently while managing priorities effectively.
• Excellent customer service, communication, and critical thinking skills.
• Ability to handle confidential information with discretion.

Preferred Qualifications:

• Three years of clinical nursing experience in Inpatient/Outpatient settings, Utilization Review, Medical Review, or Quality Assurance.
• Proficiency in using multiple screens and software programs simultaneously.
• Training and experience in ICD coding.