Registered Nurse/Medicaid Clinical Reviewer - REMOTE

Job description

Registered Nurse/Medicaid Clinical Reviewer

✔️ Location: Remote
✔️ Employment Type: Full-time
✔️ Hourly Rate: $50/hr

✅ Why Join Us
✔️ Competitive Pay: $45–$50/hr based on experience
✔️ Benefits: Paid vacation, 6 major holidays, sick leave, license reimbursement, health insurance eligibility, 401k matching, Payactiv perks
✔️ Work-Life Balance: Fully remote, Monday–Friday, 9:00 AM–5:30 PM
✔️ Growth & Impact: Contribute to Medicaid quality oversight and mission-driven healthcare initiatives in a supportive environment

✅ Qualifications
✔️ Graduate of an accredited nursing program
✔️ Active RN and NY State licenses
✔️ 1–3 years experience in case review, utilization, billing, coding; InterQual and Milliman experience required
✔️ Proficient with Microsoft Outlook, Word, Excel; strong computer literacy
✔️ Analytical, detail-oriented, and able to work independently in a remote setting

✅ Key Responsibilities
✔️ Conduct utilization and Medicaid quality reviews, including chart screening and electronic documentation
✔️ Make level-one denial decisions when appropriate and participate in final-level insurance appeals
✔️ Review inpatient high-cost hospital stays using InterQual criteria and validate itemized bills
✔️ Provide guidance and training to administrative staff and clarify clinical review procedures
✔️ Collect and analyze clinical study data to support quality improvement initiatives
✔️ Maintain accurate, timely documentation and complete other related tasks as needed