Medical Claim Review Nurse

Job Title: Medical Claim Review Nurse
Locations: Orlando, FL (Fully Remote)
Duration: 6 + Months (With possibility of Extension)
 
Schedule: Monday–Friday, 9 AM – 5 PM (local time)
Training: Monday–Friday, 9 AM – 5 PM EST
 
Job Summary:
The Clinical Appeals Reviewer is responsible for conducting clinical and medical reviews of retrospective medical claims, including previously denied cases under appeal, ensuring medical necessity and accuracy in billing and claims processing. This role involves applying advanced clinical expertise to evaluate claims in alignment with federal and state regulations, Client policies, and medical guidelines. The position also requires identifying quality of care concerns and collaborating with Medical Directors and other healthcare professionals.
 
Key Responsibilities:

• Review medical patient records against established medical criteria.
• Perform detailed clinical reviews of retrospective claims and appeals to determine medical necessity.
• Identify and report quality of care issues; refer members with special needs to appropriate programs per policy.
• Assist with complex claim reviews requiring clinical decision-making.
• Document clinical review summaries, audit findings, and payment decision justifications.
• Collaborate with Medical Directors on denial decisions and provide clinical rationale.
• Serve as a clinical resource for Utilization Management, Chief Medical Officers, physicians, and appeals inquiries.
• Provide training and mentoring for less experienced clinical staff, including LVNs and RNs.
• Manage escalated complaints related to Utilization Management and Long Term Services & Supports.
• Prepare and present cases for administrative hearings and judicial fair hearings when required.
• Administer claims payments, maintain claims records, and counsel claimants on coverage and benefits.
• Monitor and manage claims workflow to ensure timely and cost-effective settlement.

 
Qualifications:

• Minimum of 3 years clinical appeals review experience.
• Minimum of 1 year utilization review experience.
• Experience with itemized bill review is mandatory; DRG experience is preferred and will be prioritized.
• Active, unrestricted Registered Nursing (RN) license in good standing.

 
Preferred Certifications:

• Certified Clinical Coder (CCC)
• Certified Medical Audit Specialist (CMAS)
• Certified Case Manager (CCM)
• Certified Professional Healthcare Manager (CPHM)
• Certified Professional in Healthcare Quality (CPHQ)
• Other relevant healthcare certifications