Medical Claim Reviewer (CGS, DMEC-B)

Max Salary: W-2 ($65,000/$31.25)

Location: Remote (U.S. – Work from home)
Remote Work Requirements: High-speed internet (non-satellite) and a private, lockable home office
Equipment: You will be provided with all necessary equipment to perform your job effectively, including but not limited to a desktop computer, dual monitors, a headset, an ethernet cable, and additional accessories as needed.

About the Role

We are seeking a dedicated Registered Nurse (RN) 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

• Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
• Assess payment determinations using clinical information and established guidelines.
• Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement.
• Provide clear, well-documented rationales for service approvals or denials.
• Educate internal and external teams on medical review processes, coverage determinations, and coding requirements.
• Support quality control activities to meet corporate and team objectives.
• Provide guidance to LPN team members and support non-clinical staff through training and discussions.
• Assist with special projects and additional responsibilities as assigned.

Minimum Qualifications

Licensure:

• Active, unrestricted RN license in the U.S. and in the state of hire
  OR
• Active compact multistate RN license (as defined by the Nurse Licensure Compact).

Education:

• Associate Degree in Nursing
  OR
• Graduate of an accredited School of Nursing.

Experience:

• Two years of clinical experience.

Skills & Competencies:

• Strong clinical background in managed care, home health, rehabilitation, and/or medical-surgical settings.
• Ability to interpret and apply medical review criteria and clinical guidelines.
• Proficiency in Microsoft Office and word processing software.
• Strong analytical, organizational, and decision-making skills.
• Ability to work independently while managing priorities effectively.
• Excellent customer service, communication, and critical thinking skills.
• Ability to handle confidential information with discretion.