Medical Review Nurse

GRP SCAN Group; California; Hybrid; USD 55,000 - 77,000; Full time

Benefits offered by this job

Remote work

Annual bonus program

Wellness program

Generous PTO

11 holidays + floating/birthday

Job summary

SCAN Group in the United States is seeking a clinical reviewer to assess medical claims and post-service appeals, ensuring timely and accurate processing in a remote setting.

You will guide staff, interpret CMS guidelines, and contribute to complex decision making on coverage and medical necessity for Medicare beneficiaries, with emphasis on quality and compliance across states.

Qualifications

• Associate's Degree or equivalent experience required.
• Current and active California RN License in good standing required.
• Bachelor's Degree or equivalent experience preferred.
• Certified Professional Coder preferred.
• 3-5 years of related experience in clinical decision making relative to Medicare patients.
• Certifications deemed to be reasonable to function at this level.
• Performs work under minimal supervision.
• Handles complex issues and problems and refers only the most complex issues to higher-level staff.
• Possesses comprehensive knowledge of subject matter.
• Technical expertise.
• Strong technical skills for functional area.
• Problem Solving.
• Strong problem-solving skills.
• Communication.
• Good communication and interpersonal skills.
• Ability to work as part of a team.
• Oral and written communication skills.
• Attentiveness.
• Interpersonal skills.

Responsibilities

• Provide clinical review of medical claims and post service appeals.
• Facilitate appropriate investigation of issues and management of medical services and benefits administration while maintaining SCAN timeframe standards.
• Review and analyze pre and post payment of complex health care claims from a medical perspective.
• Perform audits/reviews of medical claims per established criteria, identify need for medical record review, necessary documentation to support decision making process regarding appropriateness of claim, billed charges, benefit coverages.
• Provide guidance to other staff members and accurately interpret and apply broad CMS guidelines to specific and highly variable situations.
• Conduct review of claims 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.

Skills

Communication

Problem Solving

Teamwork

Education

Associate's Degree or equivalent

California RN License

Bachelor's Degree preferred

Certified Professional Coder preferred

Job description

Founded in 1977 as the Senior Care Action Network, SCAN began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the “12 Angry Seniors.” Their mission continues to guide everything we do. Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults. Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next-generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity. At SCAN, we believe scale should strengthen—not dilute—our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve. SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation’s leading not-for-profit Medicare Advantage plans, serving more than 300,000 members in California, Arizona, Nevada, Texas, New Mexico & Washington. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 45 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on LinkedIn, Facebook, and Twitter.

The Job

Provide clinical review of medical claims and post service appeals.
Facilitate appropriate investigation of issues and management of medical services and benefits administration while maintaining SCAN timeframe standards.

• Review and analyze pre and post payment of complex health care claims from a medical perspective.
• Perform audits/reviews of medical claims per established criteria, identify need for medical record review, necessary documentation to support decision making process regarding appropriateness of claim, billed charges, benefit coverages.
• Provide guidance to other staff members and accurately interpret and apply broad Centers for Medicare and Medicaid Services (CMS) guidelines to specific and highly variable situations.
• Conduct review of claims 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) as assigned and as necessary and appropriate.
• Process workload and complete project work in the appropriate computer system(s).
• Contribute to team effort by accomplishing related results as needed.
• Route identified clinical and/or risk issues to appropriate personnel e.g., Medical Director, Quality of Care (QOC) Nurse, Medical Management Specialist, Member Services, etc.
• Review/prepare potential claims denials in conjunction with Medical Director.
• Collaborate with Medical Director pursuant to adjudication of claims and post service appeals.
• Participate in special projects/workgroups/committees (eg, interdisciplinary workgroups, report analysis, independent review entity (IRE) etc. as assigned and as necessary and appropriate).

Your Qualifications

• Associate's Degree or equivalent experience required.
• Current and active California RN License in good standing required.
• Bachelor's Degree or equivalent experience preferred.
• Certified Professional Coder preferred.
• 3-5 years of related experience in clinical decision making relative to Medicare patients.
• Certifications deemed to be reasonable to function at this level.
• Performs work under minimal supervision.
• Handles complex issues and problems and refers only the most complex issues to higher-level staff.
• Possesses comprehensive knowledge of subject matter.
• Technical expertise.
• Strong technical skills for functional area.
• Problem Solving.
• Strong problem‑solving skills.
• Communication.
• Good communication and interpersonal skills.
• Ability to work as part of a team.
• Oral and written communication skills.
• Problem‑solving skills.
• Attentiveness.
• Interpersonal skills.

What's in it for you?

• Base salary range: $38.61 to $55.86 per hour.
• Remote position.
• An annual employee bonus program.
• Robust Wellness Program.
• Generous paid-time‑off (PTO).
• Eleven paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday.
• Excellent 401(k) Retirement Saving Plan with employer match and contribution.
• Robust employee recognition program.
• Tuition reimbursement.
• An opportunity to become part of a team that makes a difference to our members and our community every day!

At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more. SCAN is proud to be an Equal Employment Opportunity and Aff‑firmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required. Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities.

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c).

Become part of a mission-driven team that makes a difference in the lives of seniors every day. SCAN has a long history of finding and investing in ways to meet seniors' needs. This focus is what attracts employees to SCAN. For each and every one of us, the SCAN mission is personal. Keeping Seniors Healthy and Independent is both our mission and our passion. That same commitment carries over to our employees. We provide the training, tools and support necessary to do your work. We reward effort and celebrate success. SCAN both develops and attracts people who are leading experts in their respective fields.

Why consider a career at SCAN?

• A competitive compensation and benefits program.
• An annual employee bonus program.
• Generous paid-time‑off (PTO).
• Eleven paid holidays per year.
• Excellent Retirement Savings program.
• A work‑life balance.
• An opportunity to become part of a team that makes a difference to our members and our community every day!