Clinical Claims Reviewer - RN

Location: Remote

Schedule: Monday – Friday, 8:00 AM – 5:00 PM EST

The Clinical Claims Reviewer, RN is responsible for performing utilization management (UM) reviews within the scope of nursing licensure for provider post-payment inquiries, reconsiderations, and authorization reviews. This role conducts comprehensive medical necessity reviews for inpatient, outpatient, concurrent, retrospective, pre-payment, and post-payment cases while ensuring compliance with regulatory requirements, health plan policies, and established clinical guidelines.

Key Responsibilities

• Perform utilization management reviews to determine medical necessity for pre-payment and post-payment reconsiderations and authorization requests.
• Review inpatient, outpatient, concurrent, retrospective, and referral cases using established clinical criteria and health plan policies.
• Evaluate member eligibility, benefits, and coverage guidelines when making review determinations.
• Apply MCG, CMS, DMAS, health plan, and vendor-specific criteria to support clinical decision-making.
• Identify cases requiring escalation and refer complex reviews to Medical Directors as appropriate.
• Ensure compliance with regulatory and accreditation standards, including NCQA, CMS, DMAS, and Bureau of Insurance (BOI) requirements.
• Document review findings accurately and maintain detailed case records.
• Prepare and issue line-of-business-specific written determinations and notifications to providers.
• Maintain productivity and quality standards while meeting departmental turnaround times.
• Support audit readiness and participate in quality improvement initiatives

Required Qualifications

• Active, unrestricted Registered Nurse (RN) license in the Commonwealth of Virginia.
• Minimum of 3 years of acute care nursing experience.
• Strong clinical assessment and critical-thinking skills.
• Knowledge of medical necessity review processes and utilization management principles.
• Experience interpreting clinical documentation and applying evidence-based criteria.
• Excellent written and verbal communication skills.
• Strong organizational skills with the ability to manage multiple priorities in a deadline-driven environment.
• Proficiency with electronic medical records and healthcare systems

Job Type & Location

This is a Contract position based out of Richmond, VA.

The pay range for this position is $45.00 - $50.00/hr.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: • Medical, dental & vision • Critical Illness, Accident, and Hospital • 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available • Life Insurance (Voluntary Life & AD&D for the employee and dependents) • Short and long-term disability • Health Spending Account (HSA) • Transportation benefits • Employee Assistance Program • Time Off/Leave (PTO, Vacation or Sick Leave)

This is a fully remote position.

This position is anticipated to close on Aug 7, 2026.

About TEKsystems

We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change. That's the power of true partnership. TEKsystems is an Allegis Group company.

The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

About TEKsystems and TEKsystems Global Services

We’re a leading provider of business and technology services. We accelerate business transformation for our customers. Our expertise in strategy, design, execution and operations unlocks business value through a range of solutions. We’re a team of 80,000 strong, working with over 6,000 customers, including 80% of the Fortune 500 across North America, Europe and Asia, who partner with us for our scale, full-stack capabilities and speed. We’re strategic thinkers, hands-on collaborators, helping customers capitalize on change and master the momentum of technology. We’re building tomorrow by delivering business outcomes and making positive impacts in our global communities. TEKsystems and TEKsystems Global Services are Allegis Group companies. Learn more at TEKsystems.com.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

San Francisco Fair Chance Ordinance: Pursuant to the San Francisco Fair Chance Ordinance, for all positions located in the city and county of San Francisco, we will consider for employment qualified applicants with arrest and conviction records.

Massachusetts Lie Detector: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Use of Artificial Intelligence (AI): We may use Artificial Intelligence (AI) to support parts of our hiring process, including sourcing, screening, and evaluating candidates. AI helps assess applications and qualifications, but final decisions are made by our hiring team. By applying, you acknowledge and agree that your application may be reviewed using AI tools.