Clinical Reviewer assessing medical product evaluations under MDR regulations. Collaborating with experts to ensure compliance and quality in assessments.
About the role
- Conduct medical claim reviews for Durable Medical Equipment (DME) claims including complex services, pre-authorizations, appeals, fraud investigations, and coding accuracy
- Use established clinical guidelines and protocol sets to make coverage and reimbursement determinations
- Ensure claims meet contractor standards and comply with Medicare guidelines
- Document medical rationale for claim approvals or denials
- Provide education and support to internal/external teams regarding medical reviews, coverage determinations, and coding procedures
- Participate in quality control activities and support LPN team members
- Assist with special projects and additional responsibilities as assigned
Requirements
- Active, unrestricted RN license in the U.S. or active compact multistate RN license under the Nurse Licensure Compact (NLC)
- Associate’s degree in a related field OR graduate of an Accredited School of Nursing
- Minimum two years of clinical nursing experience
- Ability to work independently, prioritize tasks, and make sound decisions
- Strong analytical, critical thinking, and organizational skills
- Proficiency in Microsoft Office and ability to work with multiple software programs
- Ability to handle sensitive information with discretion (confidentiality)
- High-speed (non-satellite) internet and a private home office for remote work
- May be required to work onsite if living within driving distance of Nashville, TN
- Background check and drug test required prior to start; some positions may require fingerprinting
- Preferred: Medicare Part B experience
- Preferred: Medicare DME claims experience (strongly preferred)
- Preferred: Intermediate computer proficiency with multitasking capabilities
Benefits
- 401(k) with company match
- Dental insurance
- Medical insurance
- Life & Disability insurance
- Paid Time Off - the longer you stay, the more you earn!
- Paid Holidays
Job title
Job type
Experience level
Salary
Not specified
Degree requirement
Location requirements
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