Location
United States
Job Type
Full-time
Posted
July 18, 2026
Job Description
Our Client, a Healthcare company, is looking for a Nurse RN 5 for their Remote location. Responsibilities:
+ Reviews for medical necessity, coding accuracy, medical policy compliance and contract compliance.
+ Triages and prioritizes cases to meet required turn-around times.
+ Prepares and presents cases electronically to the Medical Director (MD) for approvals or denials and medical necessity determination.
+ Communicate determinations to providers in compliance with state, federal and accreditation requirements.
+ Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate.
+ Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments, as necessary.
+ Assists in the development and implementation of a proactive approach to improve and standardize overall retro claims review for clinical perspectives.
...
+ Reviews for medical necessity, coding accuracy, medical policy compliance and contract compliance.
+ Triages and prioritizes cases to meet required turn-around times.
+ Prepares and presents cases electronically to the Medical Director (MD) for approvals or denials and medical necessity determination.
+ Communicate determinations to providers in compliance with state, federal and accreditation requirements.
+ Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate.
+ Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments, as necessary.
+ Assists in the development and implementation of a proactive approach to improve and standardize overall retro claims review for clinical perspectives.
...