Job Description

Job Title: Medical Claims Reviewer - RN

Duration: 3+ months (Temp to Perm)

Location: Remote (Eligible States: AK, AR, AZ, CA, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI, WY)

Job Summary:

• We are seeking a dedicated RN to conduct retrospective reviews of behavioral health and medical/surgical claims for both inpatient and outpatient services.
• This role involves assessing medical necessities, benefit coverage, quality of care, and length of stay. You will utilize your clinical, coding, and processing expertise to ensure adherence to program benefits and provide essential clinical information to relevant teams.

Key Responsibilities:

• Review medical claims using established guidelines and clinical criteria to evaluate medical necessity and appropriateness of care.
• Prepare cases for medical director review as needed.
• Validate data provided with program invoices and ensure compliance with contract timelines.
• Identify process improvements and report potential quality or fraud issues.
• Communicate effectively with management and peers.
• Meet production and quality metrics consistently.

Education & Experience:

Required:

• Active, unrestricted RN license
• U.S. Citizen
• Minimum 2 years of clinical experience in direct patient care (medical or behavioral health)
• Minimum 2 years of Utilization Management (UM) experience or medical claims processing
• Preferred:
• 2+ years in Managed Care
• 1+ year with TRICARE
• Familiarity with Current Procedural Terminology (CPT)

Competencies:

• Strong coaching and mentoring abilities
• Commitment to tasks and adherence to policies
• Excellent communication and people skills
• Proficient in a multi-system Microsoft environment
• Strong organizational and technical skills

Working Conditions:

• Ability to work independently from home.
• Prolonged computer uses with extended sitting.

Benefits:

• Comprehensive medical, dental, and vision coverage
• Generous paid time off
• 401(k) retirement savings plan (with matching)
• Tuition reimbursement and paid volunteer time

Company Overview:

• Here Healthcare Alliance, we are dedicated to serving those who served. Join our mission to connect America's heroes to healthcare in their communities.

Equal Employment Opportunity:

• We value diversity and encourage all qualified candidates to apply, regardless of background or identity.

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