The nurse reviewer conducts medical record and documentation reviews to support independent dispute resolution cases at the federal and state levels, with a focus on billing, coding, and determining whether claims are appropriately supported. The role also involves quality assurance checks, case preparation, and drafting determination correspondence for disputed healthcare claims involving providers, facilities, and payers. This is a remote office-based position that works closely with clinical reviewers, physicians, attorneys, and legal staff.
Key Responsibilities
- Conduct initial assessments of documentation submitted by initiating and responding parties.
- Review medical records and related materials to identify missing information needed to resolve disputes.
- Determine the appropriate clinical reviewer type needed for each case, such as a medical coder or physician.
- Prepare case documents for arbitrator reviewers and provide instructions as needed.
- Collaborate with legal staff to support dispute resolution.
- Draft professional determination correspondence and amend reports when additional clinical information is needed.
- Perform quality assurance checks and audit patient records in accordance with federal or state guidance.
- Research regulation changes and apply appropriate guidelines on a case-by-case basis.
Required
- Active nursing license, at minimum RN.
- Unrestricted nursing license in any U.S. state.
- Five years of full-time equivalent experience providing direct patient care.
Preferred
- Ability to analyze clinical documentation and apply guidelines accurately.
- Experience with appeal or claim dispute review processes.
- Medical coding certification.
- Prior utilization review experience.
- Familiarity with electronic documents and tools such as PDF files, Excel, Word, Outlook, SharePoint, or ShareFile.
- Strong written and verbal communication, organization, and attention to detail.
Benefits & Perks
- Remote work arrangement.
- Part-time schedule.
- Weekend and holiday shifts may be part of the schedule.
- Salary range of $45-$55 per hour.