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Medical Claims Review Nurse - Full Remote

Long Beach, CA

Position Title: Medical Claims Review Nurse
Type: Fully Remote

Schedule: Monday to Friday, 9:00 AM to 5:00 PM PST/PDT
Candidates must live in Pacific Time Zone

Daily Responsibilities:

  • Reviewing medical patient records against standard medical criteria.

Minimum Qualifications:

  • Three years of clinical appeals experience.
  • One year of utilization review experience.
  • Candidates with DRG experience on their resume will be prioritized for interviews.

Job Summary:

  • Perform clinical/medical reviews of retrospective medical claim reviews, medical claims, and previously denied cases.
  • Ensure medical necessity and appropriate/accurate billing and claims processing.
  • Identify and report quality of care issues.
  • Refer members with special needs to appropriate healthcare organization programs.
  • Assist with complex claim review requiring decision-making based on clinical experience.
  • Document clinical review summaries, bill audit findings, and audit details in the database.
  • Provide supporting documentation for denial and modification of payment decisions.
  • Re-evaluate medical claims independently by applying advanced clinical knowledge and relevant regulatory requirements.
  • Review clinical guidelines with Medical Directors on denial decisions.
  • Serve as a clinical resource for various stakeholders.
  • Provide training, leadership, and mentoring.
  • Resolve escalated complaints regarding utilization management and long-term services and supports.
  • Prepare and present cases for various hearings as required.

Job Function:

  • Administer claims payments, maintain claim records, and provide counsel to claimants.
  • Monitor and control backlog and workflow of claims.
  • Ensure timely settlement of claims in accordance with cost control standards.

Required Education:

  • BSN Preferred.

Required Experience:

  • Minimum three years of clinical appeals review experience.
  • Minimum one year of utilization review.

Required License, Certification, Association:

  • Active, unrestricted State Registered Nursing (RN) license in good standing.
  • LPN/LVN Considered based on experience
Compensation and Benefits:
  • $90,000 and up plus full benefit package

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