Full-Time
Registered Nurse Medical Reviewer
Medicare-Home Health
Posted on 8/20/2026
Broadway Ventures
Compensation Overview
$62 - $65/hr
Remote in USA
Remote
Bachelor's, Associate's
Category
 Medical, Clinical & Veterinary (1) |
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Required Skills
Microsoft Office
Quality Assurance (QA)
Requirements
- An active, unrestricted Registered Nurse license in the United States and the state of hire, or an active compact multistate Registered Nurse license under the Nurse Licensure Compact.
- An Associate Degree in Nursing or graduation from an accredited School of Nursing.
- Two years of clinical experience plus at least two years in inpatient or outpatient settings, utilization or medical review, or quality assurance.
- A strong clinical background in managed care and/or inpatient and outpatient settings.
- The ability to interpret and apply medical review criteria and clinical guidelines.
- Proficiency in Microsoft Office and word processing software.
- Strong analytical, organizational, and decision-making skills.
- The ability to work independently while managing competing priorities.
- Excellent customer service, communication, and critical thinking skills.
- The ability to handle confidential information with discretion.
Responsibilities
- Review medically complex claims, pre-authorization requests, appeals, and fraud and abuse referrals.
- Assess payment determinations using clinical information and established guidelines.
- Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement.
- Provide clear, well-documented rationales supporting approval or denial of services.
- Educate internal and external teams on medical review processes, coverage determinations, and coding requirements.
- Support quality-control activities that advance corporate and team objectives.
- Assist with special projects and additional duties as assigned.