Clinical Claims Reviewer - RN

TEKsystems•Richmond, VA

1d•$45 - $50•Remote

About The Position

The Clinical Claims Reviewer, RN is responsible for performing utilization management (UM) reviews within the scope of nursing licensure for provider post-payment inquiries, reconsiderations, and authorization reviews. This role conducts comprehensive medical necessity reviews for inpatient, outpatient, concurrent, retrospective, pre-payment, and post-payment cases while ensuring compliance with regulatory requirements, health plan policies, and established clinical guidelines.

Requirements

Active, unrestricted Registered Nurse (RN) license in the Commonwealth of Virginia.
Minimum of 3 years of acute care nursing experience.
Strong clinical assessment and critical-thinking skills.
Knowledge of medical necessity review processes and utilization management principles.
Experience interpreting clinical documentation and applying evidence-based criteria.
Excellent written and verbal communication skills.
Strong organizational skills with the ability to manage multiple priorities in a deadline-driven environment.
Proficiency with electronic medical records and healthcare systems

Responsibilities

Perform utilization management reviews to determine medical necessity for pre-payment and post-payment reconsiderations and authorization requests.
Review inpatient, outpatient, concurrent, retrospective, and referral cases using established clinical criteria and health plan policies.
Evaluate member eligibility, benefits, and coverage guidelines when making review determinations.
Apply MCG, CMS, DMAS, health plan, and vendor-specific criteria to support clinical decision-making.
Identify cases requiring escalation and refer complex reviews to Medical Directors as appropriate.
Ensure compliance with regulatory and accreditation standards, including NCQA, CMS, DMAS, and Bureau of Insurance (BOI) requirements.
Document review findings accurately and maintain detailed case records.
Prepare and issue line-of-business-specific written determinations and notifications to providers.
Maintain productivity and quality standards while meeting departmental turnaround times.
Support audit readiness and participate in quality improvement initiatives