Registered Nurse (RN) reviews medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals to determine medical necessity, appropriateness, and reimbursement eligibility. The work is fully remote and centers on pre- and post-payment medical review, documentation of coverage decisions, and application of clinical criteria and guidelines. This role also supports quality control, educates internal and external teams, and provides guidance to LPN staff.
Key Responsibilities
- Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
- Assess payment determinations using clinical information and established medical review criteria.
- Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement.
- Provide clear, well-documented rationales for approvals and denials.
- Educate internal and external teams on medical review processes, coverage determinations, and coding requirements.
- Support quality control activities to meet team and corporate objectives.
- Provide guidance to LPN team members and support non-clinical staff through training and discussion.
- Assist with special projects and other assigned responsibilities.
Required
- Active, unrestricted RN license in the U.S. and in the state of hire, or active compact multistate RN license.
- Associate Degree in Nursing or graduation from an accredited School of Nursing.
- At least 2 years of clinical experience.
- Clinical background in managed care, home health, rehabilitation, and/or medical-surgical settings.
- Ability to interpret and apply medical review criteria and clinical guidelines.
- Proficiency with Microsoft Office and word processing software.
Preferred
- Experience working in medical review or utilization-related workflows.
- Strong analytical, organizational, and decision-making skills.
- Experience working independently while managing competing priorities.
- Excellent customer service, communication, and critical thinking skills.
Benefits & Perks
- Fully remote work from home.
- Company-provided equipment, including desktop computer, dual monitors, headset, ethernet cable, and additional accessories as needed.
- Maximum W-2 salary of $65,000/$31.25.