In this fully remote RN role, you review complex claims, pre-authorization requests, appeals, and fraud and abuse referrals, using clinical judgment to determine medical necessity and support payment decisions. The work centers on coverage review for medically complex cases across inpatient and outpatient settings, with regular documentation of approval or denial rationales and consultation on coding and review criteria. You also help educate internal and external teams, support quality control, and assist with special projects as needed.
Key Responsibilities
- Review medically complex claims, pre-authorization requests, appeals, and fraud and abuse referrals
- Assess medical necessity, appropriateness, and reasonableness for coverage and reimbursement decisions
- Provide clear, well-documented rationales supporting approval or denial of services
- Apply established medical review criteria, coverage guidelines, and clinical information to payment determinations
- Educate internal and external teams on medical review processes, coverage determinations, and coding requirements
- Support quality control activities that advance team and corporate objectives
- Assist with special projects and additional duties as assigned
Required
- Active, unrestricted RN license in the United States 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 additional years of experience in inpatient or outpatient settings, utilization or medical review, or quality assurance
- Strong clinical background in managed care and/or inpatient and outpatient settings
- Ability to interpret and apply medical review criteria and clinical guidelines
Preferred
- Experience in medical-surgical, rehabilitation, or skilled nursing facility settings
- Proficiency with Microsoft Office and word processing software
- Experience working independently while managing competing priorities
- Strong analytical, organizational, decision-making, communication, and critical thinking skills
Benefits & Perks
- Fully remote work
- Full-time schedule
- 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