Medical Claim Reviewer (CGS, DMEC)
Remote (U.S. – Work from home)Full-TimeMiddle
Salary65,000 USD per year
Apply NowOpens the employer's application page
Job Details
- Experience
- Two years
- Required Skills
- Microsoft Office
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
- Two years of clinical experience
- 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
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.
View Full Description & ApplyYou'll be redirected to the employer's site
