Clinical Review Nurse

Amerit Consulting; California; Remote; USD 90,000 - 99,000; Full time

Job summary

Amerit Consulting seeks a Post-Service Clinical Review Nurse for the Federal Employee Program (FEP) Post-Service Clinical Review department on a 3-month contract with potential extension or conversion. This remote role offers $65–$72/hr on W2.

You will perform retrospective reviews of billed physician services and outpatient facility services to assess medical necessity, policy compliance, and coding accuracy, coordinating with claims and appeals teams to ensure proper provider payment and

Qualifications

• Nursing license required.
• At least 10 years of nursing experience.
• Strong clinical background.
• Familiarity with outpatient procedures and diagnostic tests.
• Proficiency in using technology.

Responsibilities

• Perform clinical claim reviews and first-level claim determinations using FEP guidelines.
• Review claims for medical necessity, coding accuracy, and policy compliance.
• Prepare and present cases to the Medical Director for determinations.
• Communicate determinations to providers/members per regulations.
• Develop member-centered documentation reflecting determinations.
• Triage cases to meet turnaround times and metrics.
• Identify quality-of-care issues and intervene as appropriate.
• Refer cases to Case Management, Disease Management, Appeals and Grievances, and Quality.
• Help improve retrospective claims review from a clinical perspective.
• Perform other duties as assigned.

Skills

Nursing license

10+ years exp

Clinical expertise

Outpatient procedures

Tech proficiency

Education

Bachelor’s degree in nursing

Post-service clinical review experience

Job description

Duration: 3 Months (Contract, potential to extend or convert)

Pay Rate: $65–$72/hr on W2

Work Arrangement: Remote

Position Summary

The Federal Employee Program (FEP) Post-Service Clinical Review department performs retrospective reviews of billed physician services and related outpatient facility services against FEP medical benefit and payment policies.

Reporting to the Manager of FEP Post Services, the Post-Service Clinical Review Nurse reviews claims and medical records for medical necessity, medical policy compliance, benefits coverage, and clinical coding. This role supports the review process from initial review through final appeal, as dictated by FEP policy, and coordinates with claims and appeals departments to ensure appropriate provider payment and quality member care.

Key Responsibilities

• Perform clinical claim reviews and first-level claim determination approvals using FEP evidence-based guidelines, policies, and nationally recognized clinical criteria.
• Review claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance for outpatient services, laboratory services, durable medical equipment (DME), and medications covered under the medical benefit.
• Prepare and present cases to the Medical Director for oversight and medical necessity determinations.
• Communicate determinations to providers and/or members in compliance with federal and accreditation requirements.
• Develop and review member-centered documentation and correspondence reflecting determinations in accordance with regulatory and accreditation standards.
• Triage and prioritize cases to meet required turnaround times and production metrics.
• Identify potential quality-of-care issues and service or treatment delays, and intervene as clinically appropriate.
• Refer cases to Case Management, Disease Management, Appeals and Grievances, and Quality departments as needed.
• Assist in developing and implementing proactive approaches to improve and standardize retrospective claims review from a clinical perspective.
• Perform other duties as assigned.

Required Qualifications

• Nursing license.
• At least 10 years of experience.
• Strong clinical background.
• Familiarity with outpatient procedures and diagnostic tests.
• Proficiency in using technology.

Preferred Qualifications

• Bachelor’s degree in nursing.
• Post-service clinical review experience.
• Ability to work independently.

Company Overview:

Amerit Consulting is a nationwide staffing and consulting firm supporting Fortune 500 clients across healthcare, technology, engineering, and professional services. With over 2,000 employees across 47 states, Amerit specializes in contract, temporary, and direct hire staffing solutions.

Amerit Consulting provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. Applicants, with criminal histories, are considered in a manner that is consistent with local, state and federal laws.