This role focuses on reviewing clinical claims and supporting medical necessity determinations in a remote setting. The nurse manager works across claim review workflows, helping ensure consistent, evidence-based decisions and coordination with internal clinical and operational teams.
Key Responsibilities
- Conduct clinical claim reviews for medical necessity and appropriateness.
- Coordinate review workflows with clinical and operational partners.
- Use evidence-based criteria and documentation standards in decision-making.
- Support consistency, quality, and timeliness in claim review processes.
- Provide guidance and oversight related to nurse review activities.
Required
- Registered Nurse (RN) licensure.
- Experience in clinical review, utilization management, or related nursing practice.
- Management or supervisory experience in a clinical setting.
Preferred
- Experience with claims review or payer-side clinical review workflows.
- Familiarity with medical necessity criteria and evidence-based guidelines.
Benefits & Perks
- Remote work arrangement.