Clinical Claims Review Nurse

This role requires the nurse to exercise clinical judgment and perform the following duties:

• Review and interpret clinical documentation obtained from medical records or systems.
• Apply clinical decision-making to utilize appropriate clinical criteria and policies for post-service claims
• Coordinate clinical resolutions independently, with clinician/MD support as required
• Act as a resource for customer service and claims processing teams
• Train new staff and provide cross-training to existing team members
• Identify trends and provide feedback to leadership if discrepancies or potential fraudulent activities are identified
• Remain current with applicable laws, regulations, and internal workflows to ensure full compliance with organizational and state-specific requirements

Required Qualifications

• Must have active current and unrestricted Registered Nurse licensure in state of residence
• Nursing degree (RN)
• A minimum of 2–3 years of professional experience as a licensed Registered Nurse (RN), or equivalent clinical experience
• Strong analytical skills to assess medical claims

Education

• Bachelor's degree

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is

$26.01 - $68.55