Senior Nurse Reviewer

Accountabilities:

You will conduct comprehensive clinical and billing reviews to verify the accuracy, appropriateness, and validity of healthcare claims while maintaining established productivity and quality standards.

• Review medical claims using UB-04 forms and detailed itemized statements to validate individual charges.
• Verify itemized medical bill charges against client policies, applicable requirements, and industry standards.
• Perform utilization and level-of-care reviews by analyzing medical records and applying established criteria to assess the appropriateness and reasonableness of care.
• Evaluate clinical documentation to determine whether it supports the medical necessity of services provided.
• Apply critical thinking and sound clinical judgment while meeting production targets and quality expectations.
• Assist management with training and developing new reviewers through daily monitoring, mentoring, feedback, and education.
• Maintain current knowledge of clinical review criteria, coding guidelines, and relevant policies and regulations.
• Complete required continuing education units (CEUs) to maintain an active nursing license.
• Participate in scheduled training sessions and meetings to strengthen knowledge of clinical policies, procedures, and regulatory requirements.
• Cross-train across multiple claim types to support operational flexibility and changing client needs.

Requirements:

The ideal candidate will have a strong inpatient clinical background, hands-on itemized bill review experience, and the analytical skills needed to assess medical necessity and claims accuracy in a fast-paced environment.

• Active, unrestricted Registered Nurse (RN) license in the United States and the state of primary residence, or an active, unrestricted multistate RN license under the Nurse Licensure Compact (NLC).
• At least 5 years of clinical experience in an inpatient hospital setting.
• At least 1 year of itemized medical bill review experience.
• Familiarity with CPT, ICD-10, and HCPCS coding guidelines.
• Strong clinical assessment, critical thinking, and decision-making skills.
• Ability to manage multiple tasks and meet productivity and quality targets in a fast-paced environment.

Preferred Qualifications:

• At least 3 years of utilization review or claims auditing experience.
• Experience applying MCG or InterQual clinical criteria.
• Experience mentoring, training, or supporting the development of other reviewers.

Benefits:

• Annual salary range of $78,000–$99,200, depending on geographic location, internal equity, relevant knowledge, skills, and experience.
• Flexible vacation policy for eligible full-time salaried employees.
• 401(k) retirement plan with employer matching contributions.
• Comprehensive health benefits.
• Educational assistance.
• Leadership and technical development academies.
• Opportunities for continuous learning, professional growth, and career development.
• Remote work arrangement.

Additional Information:

• Work arrangement: Home-based, with a work location within the continental United States.
• Equipment and environment: Candidates must provide a high-speed internet connection and a distraction-free workspace.
• Working hours: Availability during normal business hours is required for regular collaboration with team members and other departments.
• Schedule flexibility: Extended hours may occasionally be required to meet business needs.
• Travel: Up to or at least 10% may be required based on business needs.
• Application deadline: October 23, 2026.