Home Health RN – Medical Claims Reviewer

Simsy Ventures

Registered Nurse conducting pre- and post-payment medical reviews for Broadway Ventures. Assessing medical necessity and providing educative support to teams involved in the process.

Posted 5/19/2026full-timeRemote • 🇺🇸 United StatesMid-LevelSenior💰 $60,000 - $63,000 per yearWebsite

About the role

Key responsibilities & impact

Conducting pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines
Assessing medical necessity, appropriateness, and reimbursement eligibility while documenting decisions
Reviewing medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals
Educating internal and external teams on medical review processes, coverage determinations, and coding requirements
Supporting quality control activities to meet corporate and team objectives
Providing guidance to LPN team members and supporting non-clinical staff through training and discussions
Assisting with special projects and additional responsibilities as assigned

Requirements

What you’ll need

Active, unrestricted RN license in the U.S. and in the state of hire OR Active compact multistate RN license
Associate Degree in Nursing OR Graduate of an accredited School of Nursing
Two years of clinical experience plus at least two years in Home Health, Utilization/Medical Review, or Quality Assurance
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.

Benefits

Comp & perks

High-speed internet requirement
Private, lockable home office requirement
Necessary equipment provided including desktop computer and accessories

ATS Keywords

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Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools

medical reviewclinical criteriamedical necessity assessmentreimbursement eligibilityclaims reviewpre-authorization requestscoding requirementsquality controlclinical guidelinesanalytical skills

Soft Skills

communication skillscustomer serviceorganizational skillsdecision-making skillscritical thinkingindependencepriority managementtrainingguidancediscretion

Certifications

RN licenseAssociate Degree in Nursing