Home Health RN – Medical Claims Reviewer
New
Remote (U.S. – Work from home), Monday–Friday, 8:00 AM – 5:00 PMFull-TimeMiddle
Salary60,000 - 63,000 USD per year
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Job Details
- Experience
- Two years of clinical experience plus at least two years in Home Health, Utilization/Medical Review, or Quality Assurance
- Required Skills
- Analytical SkillsMicrosoft OfficeQuality Assurance
Requirements
- 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.
- Minimum 2 years of clinical experience.
- Minimum 2 years of experience 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.
- Excellent customer service, communication, and critical thinking skills.
- Ability to work independently.
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.
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