Remote Clinical Review Nurse – Medicare Claims Expert

Novitas Solutions, Inc.; Florida; Hybrid; USD 70,000 - 95,000; Full time

Benefits offered by this job

Medical/dental/vision insurance

Short/long-term disability

401(k) with company match

Telehealth benefits

Gym memberships

Employee Incentive Plan

Employee Assistance Program

Rewards program

Paid Time Off

Job summary

Novitas Solutions, Inc. is seeking a Clinical Review Nurse to assess health claims against national and local policies and accepted medical standards of care. You will evaluate medical necessity, prior authorization considerations, and post‑payment reviews as part of a team delivering Medicare services.

The role requires an RN license, strong communication, and the ability to work with CMS guidelines. Remote work is available in participating states including Florida, with optional in‑office or

Qualifications

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

Responsibilities

• Review and analyze pre and post pay complex health care claims from a medical perspective.
• Perform clinical review work and interpret CMS guidelines.
• Assess medical necessity, utilization, and appropriateness of care per policies.
• Identify overpayments or fraud indicators and propose corrective actions.
• Process claims and complete project work in the required systems.

Skills

Communication skills

Clinical experience

Microsoft Office proficiency

Health claim review

Education

High School diploma or GED

BSN (preferred)

Job description

Novitas Solutions, Inc. is seeking a Clinical Review Nurse to assess health claims against national and local policies and accepted medical standards of care. You will evaluate medical necessity, prior authorization considerations, and post‑payment reviews as part of a team delivering Medicare services.

The role requires an RN license, strong communication, and the ability to work with CMS guidelines. Remote work is available in participating states including Florida, with optional in‑office or