Remote RN – Medical Claims Reviewer

{"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."}

{"Three years of clinical nursing experience in Home Health, Utilization Review, Medical Review, or Quality Assurance (strongly preferred).","Proficiency in using multiple screens and software programs simultaneously."}