Registered Nurse – Medical Claims Reviewer (FES Claims) - REMOTE ROLE - RNMCR

NavitsPartners; Mesa (AZ); Remote; USD 52,000 - 75,000; Full time

Job summary

A leading healthcare company is seeking a detail-oriented Registered Nurse to perform medical claims reviews for FES 1500 claims. This remote position requires strong clinical knowledge and experience in utilization review, ensuring accurate claim evaluations and compliance with health regulations. Located candidates in or near Phoenix, AZ will be preferred.

Qualifications

• Must possess active Arizona RN License and BLS Certification.
• Experience in utilization review and emergency care necessary.
• Strong understanding of coding systems required.

Responsibilities

• Review and adjudicate FES 1500 emergency medical claims.
• Evaluate claims for medical necessity and proper coding.
• Analyze claims data for trends and savings.

Skills

Clinical knowledge

Utilization review

Medical coding

Data entry

Trend analysis

Communication

Education

Active RN License (Arizona)

BLS Certification

High school diploma or equivalent

Job description

Job Title : Registered Nurse – Medical Claims Reviewer (FES Claims)

Location : Remote (Must reside in or near Phoenix, AZ 85034)

Duration : 13 Weeks

Equipment Requirement : Personal laptop (remote desktop access will be provided)

Certifications Required :

Active Registered Nurse (RN) License – Arizona

Basic Life Support (BLS) Certification

Fingerprint Clearance Card (must be obtained prior to start)

Position Summary :

We are seeking a detail-oriented and self-driven Registered Nurse to join our team as a Medical Claims Reviewer specializing in FES 1500 claims. This role is remote, but candidates must be located in the Phoenix, AZ area. The ideal candidate will have strong clinical knowledge, experience in utilization review, and a deep understanding of emergency care criteria and medical coding standards.

Key Responsibilities :

Review and adjudicate FES 1500 emergency medical claims according to established guidelines

Evaluate claims for medical necessity, emergency status, proper coding, length of stay, and level of care

Conduct second-level reviews and provider collaboration as needed

Analyze claims data to identify trends, generate reports, and track savings

Participate in special projects and conduct related research

Apply InterQual criteria, Correct Coding Initiative (CCI) edits, and current regulations during evaluations

In-depth clinical nursing knowledge with experience in utilization review and case management

Proficiency in CPT, HCPCS, ICD-9 / 10 coding systems

Ability to interpret medical records and assess appropriate levels of care

Familiarity with managed care protocols, InterQual Criteria, and CCI edits

Knowledge of AHCCCS and CMS regulations

Strong skills in data entry, organization, and trend analysis

Independent, self-motivated, and comfortable working remotely

Excellent communication and collaboration skills

Minimum Requirements :

Active RN License (Arizona)

BLS Certification

Fingerprint Clearance Card (prior to start date)

Personal laptop for remote access

High school diploma or equivalent

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Registered Nurse Medical • Mesa, Arizona, United States