Remote Medical Review Nurse – Claims & Appeals Expert

SCAN Health Insurance; New York (NY); Remote; USD 53,000 - 77,000; Full time

Benefits offered by this job

Remote position

Annual bonus program

Wellness Program

Generous PTO

11 holidays + 1 floating + 1 birthday

Job summary

SCAN Health Insurance in the United States is seeking a qualified Clinical Reviewer to provide expert review of medical claims and post-service appeals from a clinical perspective.

You will audit complex Medicare claims, apply CMS guidelines, and collaborate with medical leadership to determine coverage and medical necessity while supporting SCAN’s mission and goals. This remote role offers a comprehensive benefits package.

Qualifications

• Associate degree or equivalent experience required.
• Current and active California RN license in good standing.
• 3–5 years of related experience in clinical decision making for Medicare patients.

Responsibilities

• Review and analyze pre- and post-payment of complex health care claims.
• Audit/review medical claims per criteria and identify needed records.
• Interpret and apply CMS guidelines to variable situations.
• Assess medical necessity, utilization and care appropriateness per policy.
• Process workload and complete project work in the designated systems.
• Route issues to Medical Director, QOC, or other staff as needed.
• Collaborate with Medical Director on claim adjudication and post-service appeals.
• Participate in special projects and interdisciplinary workgroups as assigned.
• Support SCAN’s mission and contribute to team goals.

Skills

California RN License

CMS guidelines interpretation

Clinical decision making

Team communication

Problem solving

Medicare claims review

Education

Associate degree or equivalent experience

Bachelor's degree preferred

Job description

SCAN Health Insurance in the United States is seeking a qualified Clinical Reviewer to provide expert review of medical claims and post-service appeals from a clinical perspective.

You will audit complex Medicare claims, apply CMS guidelines, and collaborate with medical leadership to determine coverage and medical necessity while supporting SCAN’s mission and goals. This remote role offers a comprehensive benefits package.