Remote Clinical Review Nurse - Medicare Claims

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

Benefits offered by this job

Remote position

Annual employee bonus program

Wellness program

Paid time off

Holidays

401(k) match

Tuition reimbursement

Recognition program

Career development

Team environment

Job summary

SCAN Group is seeking a clinical reviewer to provide expert review of medical claims and post-service appeals. You will analyze complex claims from a medical perspective, ensure CMS guideline compliance, and collaborate with the Medical Director on adjudication.

The role requires an active California RN license, 3–5 years of Medicare-claims experience, and a strong capability in clinical decision making. This is a remote, full-time position with competitive hourly compensation 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.
• Apply CMS guidelines to specific situations and interpret them accurately.
• Collaborate with Medical Director on adjudication of claims and appeals.
• Participate in special projects/workgroups as assigned.

Skills

Clinical decision making

Communication skills

Teamwork

Problem solving

Interpersonal skills

Oral and written communication

Education

Associate degree or equivalent

Bachelor's degree preferred

Job description

SCAN Group is seeking a clinical reviewer to provide expert review of medical claims and post-service appeals. You will analyze complex claims from a medical perspective, ensure CMS guideline compliance, and collaborate with the Medical Director on adjudication.

The role requires an active California RN license, 3–5 years of Medicare-claims experience, and a strong capability in clinical decision making. This is a remote, full-time position with competitive hourly compensation and benefits.