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

NavitsPartners; Tucson (AZ); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading company is seeking a detail-oriented Registered Nurse to join their team as a Medical Claims Reviewer specializing in FES 1500 claims. This remote role requires strong clinical knowledge and experience in utilization review, along with proficiency in medical coding standards. The ideal candidate will be responsible for reviewing claims, ensuring compliance with regulations, and collaborating with providers as needed. Applicants must hold an active RN license in Arizona and possess BLS certification.

Qualifications

• Active Registered Nurse (RN) License in Arizona required.
• Basic Life Support (BLS) Certification needed.
• Fingerprint Clearance Card must be obtained prior to start.

Responsibilities

• Review and adjudicate FES 1500 emergency medical claims.
• Evaluate claims for medical necessity and proper coding.
• Conduct second-level reviews and provider collaboration.

Skills

Clinical knowledge

Utilization review

Medical coding

Data entry

Trend analysis

Communication

Collaboration

Education

High school diploma or equivalent

Active RN License (Arizona)

BLS Certification

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

Create a job alert for this search

Registered Nurse Medical • Tucson, Arizona, United States