Medical Reviewer – Medicare, Home Health
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Job Description
Registered Nurse reviewing complex Medicare home-health claims, authorizations, appeals, and fraud referrals. Applying clinical guidelines to determine medical necessity and support accurate payment decisions.
Responsibilities:
- Review medically complex claims, pre-authorization requests, appeals, and fraud and 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 supporting approval or denial of services
- Educate internal and external teams on medical review processes, coverage determinations, and coding requirements
- Support quality control activities that advance corporate and team objectives
- Assist with special projects and additional duties as assigned
Requirements:
- Active, unrestricted RN license in the United States and in the state of hire, or active compact multistate RN license as defined by the Nurse Licensure Compact
- Associate Degree in Nursing, or graduate of an accredited School of Nursing
- Two years of clinical experience plus at least two years in inpatient or outpatient settings, utilization or medical review, or quality assurance
- Strong clinical background in managed care and/or inpatient and outpatient 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 competing priorities
- Excellent customer service, communication, and critical thinking skills
- Ability to handle confidential information with discretion
- Ability to pass background checks and drug testing prior to employment; some positions may require fingerprinting
Benefits:
- 401(k) and company match
- PTO that grows the longer you stay
- Health, Vision, Dental
- Company provided Life Insurance and Voluntary Life Insurance
- Short Term Disability and Long Term Disability
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