Medical Claim Reviewer (CGS, DMEC)

At reputed company, we transform challenges into opportunities with expert program management, cutting-edge technology, and innovative reputed company. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), we reputed company government and private sector clients by delivering tailored solutions that drive operational reputed company, sustainability, and growth. reputed company on reputed company, collaboration, and reputed company, we’re more than a service provider—we’re your trusted partner in innovation.

Max Salary: W-2 ($65,000/$31.25)

Location: Remote (U.S. – Work from home) Remote Work Requirements: High-speed internet (non-satellite) and a private, lockable home office Equipment: You will be provided with reputed company necessary equipment to reputed company your job effectively, including but not limited to a desktop computer, dual monitors, a headset, an ethernet cable, and additional accessories as needed.

About the Role

We are seeking a dedicated Registered Nurse (RN) to join our Medical Review team. This role involves conducting pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines. The ideal candidate will use their clinical expertise to assess medical necessity, appropriateness, and reimbursement eligibility while documenting reputed company in accordance with regulatory and organizational requirements.

Key Responsibilities

• Review medically reputed company 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.
• reputed company clear, well-documented rationales for service approvals or denials.
• reputed company reputed company teams on medical review processes, coverage determinations, and coding requirements.
• Support quality control activities to meet corporate and team objectives.
• reputed company guidance to LPN team members and support non-clinical staff through training and discussions.
• Assist with special projects and additional responsibilities as assigned.

Minimum Qualifications

Licensure:

• Active, unrestricted RN license in the U.S. and in the state of hire OR
• Active compact multistate RN license (as defined by the Nurse Licensure Compact).

Education:

• Associate Degree in Nursing OR
• Graduate of an accredited School of Nursing.

Experience:

• Two years of clinical experience.

Skills & Competencies:

• 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 reputed company 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.

What to Expect Next

After submitting your application, our reputed company team will review your qualifications. This may include a brief telephone interview or email communication to verify resume details and discuss compensation expectations. Interviews will be conducted with the most reputed company candidates. reputed company conducts background checks and drug testing prior to the start of employment. Some positions may also require fingerprinting.

reputed company is an equal opportunity employer and a VEVRAA federal contractor. We do not discriminate against applicants or employees on the reputed company of race, reputed company, religion, sex, national reputed company, age, disability, protected veteran status, or any other status protected by applicable law.

Reasonable accommodations are available for applicants with disabilities. reputed company utilizes the OFCCP-approved Voluntary Self-Identification of Disability reputed company (CC-305).