Clinical Review Nurse - Novitas - Remote, FL

Novitas Solutions, Inc.; Florida; Hybrid; USD 70,000 - 95,000; Full time

Benefits offered by this job

Medical/dental/vision insurance

Short/long-term disability

401(k) with company match

Telehealth benefits

Gym memberships

Employee Incentive Plan

Employee Assistance Program

Rewards program

Paid Time Off

Job summary

Novitas Solutions, Inc. is seeking a Clinical Review Nurse to assess health claims against national and local policies and accepted medical standards of care. You will evaluate medical necessity, prior authorization considerations, and post‑payment reviews as part of a team delivering Medicare services.

The role requires an RN license, strong communication, and the ability to work with CMS guidelines. Remote work is available in participating states including Florida, with optional in‑office or

Qualifications

• High School diploma or GED required.
• 2 years of clinical experience in patient care.
• Excellent written and oral communication skills.
• Demonstrated ability to evaluate medical and health care delivery issues.
• Strong computer skills including Microsoft Office.

Responsibilities

• Review and analyze pre and post pay complex health care claims from a medical perspective.
• Perform clinical review work and interpret CMS guidelines.
• Assess medical necessity, utilization, and appropriateness of care per policies.
• Identify overpayments or fraud indicators and propose corrective actions.
• Process claims and complete project work in the required systems.

Skills

Communication skills

Clinical experience

Microsoft Office proficiency

Health claim review

Education

High School diploma or GED

BSN (preferred)

Job description

Location

United States of America-USAUS

Job Description

Are you interested in joining a team of experienced healthcare experts and have the ability to shape and transform the healthcare delivery system? At our family of companies, everything we do is to help improve the lives of the nearly 12 million Medicare beneficiaries we serve and 700,000 health care providers who care for them. It is our goal to help create a better health experience for all consumers. Join our winning culture and help transform Medicare for the millions of people who rely on its services.

Benefits info:

• Medical, dental, vision, life and supplemental insurance plans effective the first day of the month following date of hire
• Short- and long-term disability benefits
• 401(k) plan with company match and immediate vesting
• Free telehealth benefits
• Free gym memberships
• Employee Incentive Plan
• Employee Assistance Program
• Rewards and Recognition Programs
• Paid Time Off and Paid Sick Leave

SUMMARY STATEMENT

The Clinical Review Nurse is responsible for reviewing and making medical determinations as to the validity of health claims and levels of payment in meeting national and local policies as well as accepted medical standards of care. The incumbent applies clinical knowledge to assess the medical necessity, level of services and appropriateness of care which may include cases requiring prior authorization, complex pre-payment medical review or post-payment medical review.

ESSENTIAL RESPONSIBILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.

90% of time will be spent on one or more of the following activities depending on assignments:

• Review and analyze pre and post pay complex health care claims from a medical perspective, inclusive of prior authorization.
• Perform clinical review work as assigned; may provide guidance to other team members and accurately interpret and apply broad CMS guidelines to specific and highly variable situations.
• Conduct review of claim data and medical records to make clinical decisions on the coverage, medical necessity, utilization and appropriateness of care per national and local policies, as well as accepted medical standards of care.
• Review provider practices and identify issues of concern, overpayment and need for corrective action as necessary; includes surfacing potential fraud and abuse or practice concerns.
• May develop recommendations for further corrective action based on medical review findings.
• May refer for review, or implement, corrective action related to medical review activities.
• May process claims and complete project work in the appropriate computer system(s).

The remaining 10% of time will be spent on the following activities depending on assignments:

• Identify providers needing education and individually educate providers who are subject to medical review processes.
• Initiate or participate in provider teaching activities, creating written teaching material, providing one on one education or education to a group as a result of a medical review (e.g., probe, progressive corrective action, consent, etc.) or appeal.
• This may involve discussion with CMS leaders and leaders in the provider community.
• Participate in special projects as assigned.

Performs other duties as the supervisor may, from time to time, deem necessary.

REQUIRED QUALIFICATIONS

• High School diploma or GED
• 2 years' clinical experience
• Clinical experience is any work that involves direct interaction with patients for the purpose of diagnosis, treatment, or hands‑on‑care
• Excellent written and oral communication skills
• Demonstrated experience with evaluating medical and health care delivery issues
• Strong computer skills to include Microsoft Office proficiency

CERTIFICATIONS, LICENSES, REGISTRATIONS

• Valid unrestricted Registered Nurse (RN) license

PREFERRED QUALIFICATIONS

• Bachelor of Science in Nursing (BSN)
• 2 years' clinical experience as a Registered Nurse (RN)
• Insurance industry experience
• Certified Coder

Requirements

The Federal Government and the Centers for Medicare & Medicaid Services (CMS) may require applicants to have lived in the United States for a minimum of three (3) years out of the last five (5) years to be employed with the Company. These years of residence do not have to be consecutive.

Background Investigation

Background Investigation: If you are selected for this position, you must undergo a pre‑employment Background Investigation, Drug Screen, and Identity Proofing documentation must be cleared prior to hire. Most positions are subject to additional Identity Proofing, Fingerprinting and additional Background Investigation screening conducted by the Federal Government to be granted Enterprise User Administration (EUA) system logical access after you begin your employment. Your continued employment is contingent upon the outcome of the complete additional screening criteria required for the position which must find that you meet the applicable government customer's requirements (e.g., suitable for access to CMS information and information systems), as well as any additional investigation which may be required throughout your employment. If you are found not suitable, your employment may be subject to corrective action, up to and including immediate termination of employment.

Identity Documentation

You must have access to a current and unrestricted REAL ID, U.S. Passport, U.S. Passport Card, Foreign Passport, or U.S. Permanent Residency Documents. Note: Employment Authorization Cards (EAD) are not a substitute for Visas or U.S. Permanent Resident Cards.

Equal Opportunity Statement

We are an Equal Opportunity/Protected Veteran/Disabled Employer.

Remote Work Locations

This opportunity is open to remote work in the following approved states: AL, AR, FL, GA, ID, IN, IO, KS, LA, MS, NE, NC, ND, OH, PA, SC, TN, TX, UT, WV, WI, WY. Specific counties and cities within these states may require further approval. In FL and PA in‑office and hybrid work may also be available.