Remote Clinical Review Nurse – Medicare Claims

Novitas Solutions, Inc.; Florida; Remote; USD 68,000 - 98,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

Disability insurance

401(k) with match

Telehealth

Gym membership

Paid time off

Paid sick leave

Employee assistance program

Job summary

Novitas Solutions, Inc. seeks a Clinical Review Nurse to review and substantiate medical determinations for health claims.

You will assess medical necessity, service levels, and appropriateness of care under national and local policies, including cases requiring prior authorization and complex reviews. The role emphasizes applying clinical knowledge to ensure accurate payment levels and compliance with accepted medical standards.

Qualifications

• High School diploma or GED required.
• 2 years' clinical experience in healthcare.
• Excellent written and oral communication skills.
• Proven ability to evaluate medical and health care delivery issues.
• Strong computer skills including Microsoft Office.

Responsibilities

• Review and analyze pre/post pay health care claims from a medical perspective, including prior authorization.
• Perform clinical review and interpret CMS guidelines for different cases.
• Assess medical necessity, coverage, utilization, and appropriateness of care per policy.
• Identify issues of overpayment, provider concerns, or potential fraud or abuse.
• Develop recommendations for corrective actions based on findings.

Skills

Clinical experience

Communication skills

Microsoft Office

Medical review knowledge

Education

High School diploma or GED

BSN preferred

Job description

Novitas Solutions, Inc. seeks a Clinical Review Nurse to review and substantiate medical determinations for health claims.

You will assess medical necessity, service levels, and appropriateness of care under national and local policies, including cases requiring prior authorization and complex reviews. The role emphasizes applying clinical knowledge to ensure accurate payment levels and compliance with accepted medical standards.