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RN – Medical Claims Reviewer
Simsy VenturesRemote RN conducting medical claims reviews for Broadway Ventures. Assessing medical necessity, appropriateness, and reimbursement eligibility while documenting decisions in accordance with guidelines.
About the role
Key responsibilities & impact- Conducting pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines
- 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
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
- Excellent customer service, communication, and critical thinking skills
Benefits
Comp & perks- Remote (U.S. – Work from home)
- High-speed internet (non-satellite)
- Private, lockable home office
- All necessary equipment provided
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical reviewmedical necessity assessmentcoverage determinationcoding requirements interpretationquality controlmedical review criteria applicationmanaged carehome healthutilization reviewquality assurance
Soft Skills
customer servicecommunicationcritical thinkingteam guidancetrainingdocumentationeducational supportinterpersonal skillsorganizational skillsproblem-solving
Certifications
RN licensecompact multistate RN licenseAssociate Degree in Nursing