Remote RN – Medical Claims Reviewer

Registered Nurse (RN) needed to join our Medical Review team. This role involves conducting pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines. The ideal candidate will use their clinical expertise to assess medical necessity, appropriateness, and reimbursement eligibility while documenting decisions in accordance with regulatory and organizational requirements. Key responsibilities include reviewing medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals. Assess payment determinations using clinical information and established guidelines, in addition to evaluating medical necessity, appropriateness, and reasonableness for coverage and reimbursement. Provide clear, well-documented rationales for service approvals or denials, and educate internal and external teams on medical review processes, coverage determinations, and coding requirements.