Medical Claim Review Nurse (REMOTE)

Collabera; Irving (TX); Remote; USD 70,000 - 90,000; Full time

Job summary

A leading company in the health services sector is seeking a Utilization Review Nurse to evaluate medical claims and ensure compliance with clinical guidelines. The role involves working with healthcare professionals to resolve claims and provide necessary training while managing audit processes. Candidates should possess an active RN license and relevant experience in claims review and auditing.

Qualifications

• 3+ years of nursing experience.
• 1+ year in Utilization Review or Claims Review.
• 2+ years in Claims Auditing, Coding, or Medical Necessity Review.

Responsibilities

• Review past and denied medical claims for medical necessity.
• Use clinical guidelines to make decisions.
• Work closely with doctors and document findings.

Skills

Knowledge of federal / state rules

Medical Necessity Review

Claims Auditing

Utilization Review

Documentation

Education

RN license (active and in good standing)

Job description

• Review past and denied medical claims to check if care was medically necessary and properly billed.
• Use clinical guidelines (like InterQual / MCG), Medicaid / Medicare rules, and policies to make fair decisions.
• Help with audits, appeal reviews, and complex cases like DRG validation and readmissions.
• Work closely with doctors and support teams, document findings, and provide training.
• Also identify quality issues and refer special-needs members to the right programs.

Qualifications :

• RN license (active and in good standing).
• 3+ years of nursing experience.
• 1+ year in Utilization Review or Claims Review.
• 2+ years in Claims Auditing, Coding, or Medical Necessity Review.
• Knowledge of federal / state rules, billing codes (CPT / HCPCS), and guidelines like MCG / InterQual.