This remote RN role focuses on medical review of complex claims, prior authorization requests, appeals, and fraud/abuse referrals. The clinician applies established coverage guidelines to assess medical necessity, appropriateness, and payment determinations, with work centered on documentation and review decisions rather than direct patient care. The position also includes educating internal and external teams on review processes and coding requirements, plus supporting quality control and special projects.
Key Responsibilities
- Review complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
- Assess medical necessity, appropriateness, and reasonableness for coverage and reimbursement decisions.
- Provide clear, well-documented rationales for approvals and denials.
- Apply clinical information and established review criteria to support payment determinations.
- Educate internal and external stakeholders on medical review processes, coverage determinations, and coding requirements.
- Support quality control activities and team objectives.
- Use Microsoft Office and word processing tools to complete review work and documentation.
Required
- Active, unrestricted RN license in the U.S. and in the state of hire, or an active compact multistate RN license.
- Associate degree in nursing or graduation from an accredited school of nursing.
- At least 2 years of clinical experience.
- At least 2 years of experience in inpatient/outpatient settings, utilization review, ICU/ER, or quality assurance.
- Experience with managed care and/or inpatient/outpatient clinical settings.
- Ability to work independently and manage priorities effectively.
Preferred
- 3 years of clinical nursing experience in inpatient/outpatient settings, utilization review, medical review, or quality assurance.
- Training and experience in ICD coding.
- Ability to use multiple screens and software programs simultaneously.
Benefits & Perks
- Remote, work-from-home position.
- Full-time employment.
- Health, vision, and dental coverage.
- 401(k) with company match.
- PTO that grows with tenure.
- Company-provided life insurance and voluntary life insurance.
- Short-term and long-term disability coverage.