Job Description

Senior Nurse Reviewer

Make a meaningful impact on healthcare quality and claims accuracy by applying your clinical expertise to complex medical reviews. As a Senior Nurse Reviewer, you will evaluate medical records, healthcare claims, itemized medical bills, and UB-04 forms to ensure accurate billing and appropriate levels of care. You will use clinical judgment and established criteria to assess medical necessity, validate charges, and support compliance with applicable policies and industry standards. In addition to conducting detailed reviews, you will help develop other reviewers through mentoring, training, and feedback. This remote opportunity combines clinical analysis, utilization review, and claims auditing in a collaborative, quality-focused environment. You will also benefit from opportunities for professional development and a flexible work environment.

Accountabilities:

You will conduct comprehensive clinical and billing reviews to verify the accuracy, appropriateness, and validity of healthcare claims while maintaining established productivity and quality standards.

• Review medical claims using UB-04 forms and detailed itemized statements to validate individual charges.
• Verify itemized medical bill charges against client policies, applicable requirements, and industry standards.
• Perform utilization and level-of-care reviews by analyzing medical records and applying established criteria to assess the appropriateness and reasonableness of care.
• Evaluate clinical documentation to determine whether it supports the medical necessity of services provided.
• Apply critical thinking and sound clinical judgment while meeting production targets and quality expectations.
• Assist management with training and developing new reviewers through daily monitoring, mentoring, feedback, and education.
• Maintain current knowledge of clinical review criteria, coding guidelines, and relevant policies and regulations.
• Complete required continuing education units (CEUs) to maintain an active nursing license.
• Participate in scheduled training sessions and meetings to strengthen knowledge of clinical policies, procedures, and regulatory requirements.
• Cross-train across multiple claim types to support operational flexibility and changing client needs.

Requirements:

The ideal candidate will have a strong inpatient clinical background, hands-on itemized bill review experience, and the analytical skills needed to assess medical necessity and claims accuracy in a fast-paced environment.

• Active, unrestricted Registered Nurse (RN) license in the United States and the state of primary residence, or an active, unrestricted multistate RN license under the Nurse Licensure Compact (NLC).
• At least 5 years of clinical experience in an inpatient hospital setting.
• At least 1 year of itemized medical bill review experience.
• Familiarity with CPT, ICD-10, and HCPCS coding guidelines.
• Strong clinical assessment, critical thinking, and decision-making skills.
• Ability to manage multiple tasks and meet productivity and quality targets in a fast-paced environment.

Preferred Qualifications:

• At least 3 years of utilization review or claims auditing experience.
• Experience applying MCG or InterQual clinical criteria.
• Experience mentoring, training, or supporting the development of other reviewers.

Benefits:

• Annual salary range of $78,000–$99,200, depending on geographic location, internal equity, relevant knowledge, skills, and experience.
• Flexible vacation policy for eligible full-time salaried employees.
• 401(k) retirement plan with employer matching contributions.
• Comprehensive health benefits.
• Educational assistance.
• Leadership and technical development academies.
• Opportunities for continuous learning, professional growth, and career development.
• Remote work arrangement.

Additional Information:

• Work arrangement: Home-based, with a work location within the continental United States.
• Equipment and environment: Candidates must provide a high-speed internet connection and a distraction-free workspace.
• Working hours: Availability during normal business hours is required for regular collaboration with team members and other departments.
• Schedule flexibility: Extended hours may occasionally be required to meet business needs.
• Travel: Up to or at least 10% may be required based on business needs.
• Application deadline: October 23, 2026.

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