Remote Clinical Review Nurse (Medicare/Appeals)

SCAN; Long Beach (CA); Remote; USD 53,000 - 77,000; Full time

Benefits offered by this job

Remote position

Annual employee bonus program

Wellness Program

PTO

11 holidays + 1 floating + 1 birthday

401(k) with employer match

Employee recognition program

Tuition reimbursement

Job summary

SCAN is seeking a California-licensed registered nurse to provide clinical review of medical claims and post-service appeals. You will ensure medical necessity and apply CMS guidelines to complex cases from a medical perspective.

Responsibilities include pre/post-payment analysis, auditing claims, guiding staff, and collaborating with the Medical Director on denials and appeals. This is a remote position with competitive pay and benefits.

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.

Responsibilities

• Provide clinical review of medical claims and post service appeals.
• Facilitate investigation of issues and management of medical services and benefits administration.
• Review and analyze pre and post payment of complex health care claims from a medical perspective.
• Audit/review medical claims per established criteria and determine need for medical record review.
• Interpret CMS guidelines and apply to varied situations.
• Collaborate with Medical Director on adjudication of claims and post service appeals.

Education

Associate's Degree or equivalent experience

Bachelor's Degree or equivalent experience

Certified Professional Coder

3-5 years of related experience in clinical decision making

Strong problem solving

Good communication and interpersonal skills

Ability to work as part of a team

Tools

California RN License

Job description

SCAN is seeking a California-licensed registered nurse to provide clinical review of medical claims and post-service appeals. You will ensure medical necessity and apply CMS guidelines to complex cases from a medical perspective.

Responsibilities include pre/post-payment analysis, auditing claims, guiding staff, and collaborating with the Medical Director on denials and appeals. This is a remote position with competitive pay and benefits.