Senior Nurse Reviewer- Remote

Summary

We are seeking a talented individual for a Senior Nurse Reviewer to perform reviews of medical records, healthcare claims, itemized medical bill, and UB-04 forms to ensure accuracy, compliance, and proper billing practices.  This position requires clinical review expertise, as well as itemized bill review experience.

Your role in our mission

• Perform an in-depth review of medical claims utilizing the UB-04 and detailed itemized statement to ensure the validity of line-item charges.
• Verify accuracy of the itemized charges in accordance with client policy and industry standards.
• Perform level of care and utilization review by analyzing medical records and comparing against criteria to determine appropriateness and reasonableness of care.
• Apply critical thinking and decision making skills to determine if the medical record documentation supports the need for service while maintaining production goals and quality standards.
• Assists management with training new reviewers to include daily monitoring, mentoring, feedback and education.
• Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license.
• Responsible for attending training and scheduled meetings to enhance skills and working  knowledge of clinical policies, procedures, rules, and regulations.
• Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.

What we're looking for

• Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required
• 5+ years clinical experience in an inpatient hospital setting required
• 1+ year itemized bill review experience required
• 3+ years utilization review experience or claims auditing preferred
• Experience with CPT, ICD-10, and HCPCS coding guidelines
• Experience using MCG or InterQual criteria preferred
• Ability to multi-task in a fast-paced production environment.

What you should expect in this role

• Home based position and you must have a work location within the continental US
• This position requires that you provide high speed internet connection and a work environment free from distractions
• Ability to work during normal business hours as this position requires frequent interactions with the team and other departments within the company
• May be required to work extended hours for special business needs
• May be required to travel at least 10% of time based on business needs

Will accept application until October 23, 2026.