Remote Clinical Claims Reviewer (RN)

SCAN Health Plan; United States; Remote; USD 53,000 - 77,000; Full time

Benefits offered by this job

Remote position

Annual employee bonus program

Wellness program

PTO and holidays

401(k) with employer match

Tuition reimbursement

Employee recognition program

Job summary

SCAN Health Plan is seeking a qualified Nurse Reviewer to perform clinical review of medical claims and post-service appeals. The role involves applying CMS guidelines, adjudicating coverage decisions, and collaborating with the Medical Director to ensure medical necessity and appropriate utilization.

The ideal candidate holds an active California RN license, an Associate’s degree or higher, and 3–5 years of Medicare-related decision-making experience.

Qualifications

• Associate's Degree or equivalent experience required.
• Current 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 for Medicare patients.
• Certifications deemed reasonable to function at this level.

Responsibilities

• Review pre- and post-payment of complex health care claims from a medical perspective.
• Audit/review medical claims per criteria; identify need for medical record review and documentation.
• Apply CMS guidelines to specific situations.
• Determine medical necessity, utilization, and appropriateness of care per policies and standards.
• Process workload and complete projects in the computer system; contribute to team results.
• Route identified issues to Medical Director or other care staff.
• Review/prepare potential denials with Medical Director.
• Collaborate with Medical Director on adjudication of claims and post-service appeals.
• Participate in special projects/workgroups as assigned.

Skills

Clinical decision making

Communication

Team collaboration

Problem solving

Attention to detail

Oral and written communication

Interpersonal skills

Education

Associate's Degree or equivalent experience

Bachelor's Degree or equivalent experience

Job description

SCAN Health Plan is seeking a qualified Nurse Reviewer to perform clinical review of medical claims and post-service appeals. The role involves applying CMS guidelines, adjudicating coverage decisions, and collaborating with the Medical Director to ensure medical necessity and appropriate utilization.

The ideal candidate holds an active California RN license, an Associate’s degree or higher, and 3–5 years of Medicare-related decision-making experience.