Remote Claims Review Nurse - Dispute Resolution Expert

Capitol Bridge.; Virginia (IL); Hybrid; USD 75,000 - 85,000; Full time

Job summary

Capitol Bridge seeks an experienced Claims Review Nurse to resolve healthcare claim disputes under state IRO programs. You will evaluate documentation, coordinate with clinical reviewers, and work with health plans, providers, and enrollees to reach timely determinations with accuracy and professional integrity.

This remote position supports state-wide health plan disputes, requires active nursing licensure and at least five years of patient care experience, and emphasizes compliance with CPT

Qualifications

• Active nursing license required.
• Five years of full-time equivalent direct patient care experience.
• Non-restricted nursing license in any US state.

Responsibilities

• Conduct an initial assessment of documentation from initiating and responding parties.
• Review submitted documentation to identify missing items and obtain necessary documentation.
• Determine the appropriate clinical reviewer (e.g., medical coder or physician).
• Prepare materials for the clinical reviewer and provide guidance as needed.
• Collaborate with legal to facilitate dispute resolution and draft determinations.
• Communicate with enrollees, health plans, and providers to resolve disputes.
• Ensure timely delivery of determinations and maintain privacy rules.
• Familiarize with CPT coding and relevant guidelines as needed.
• Participate in required meetings and team coordination.

Skills

Nursing communication

English written and verbal

Claim review experience

Independent review processes

Education

Active nursing license

Non-restricted nursing license (any state)

Tools

SharePoint

ShareFile

Microsoft Excel

Microsoft Word

Microsoft Outlook

Job description

Capitol Bridge seeks an experienced Claims Review Nurse to resolve healthcare claim disputes under state IRO programs. You will evaluate documentation, coordinate with clinical reviewers, and work with health plans, providers, and enrollees to reach timely determinations with accuracy and professional integrity.

This remote position supports state-wide health plan disputes, requires active nursing licensure and at least five years of patient care experience, and emphasizes compliance with CPT