Medical Necessity & Post-Service Clinical Review Nurse

Job Title: Nurse RN 5 - Medical Necessity & Post-Service Clinical Review Nurse
Location: Remote
Duration: 3+ Month (Possible Extensions & Conversion)
Schedule: Monday-Friday | 8:00 AM - 3:30 PM PST
Hours: 40 Hours/Week

Pay Range: XXXXXXXXXXX - XXXXXXXXXXX Per hr on w2.
Interview: One Round Panel Interview (Video Required)

Position Overview


We are seeking an experienced Registered Nurse (RN) to support post-service clinical reviews and retrospective claims evaluations. This role is responsible for reviewing medical necessities, coding accuracy, medical policy compliance, and contract compliance while ensuring timely and accurate determinations. The RN will work independently, collaborate with Medical Directors, and support quality improvement initiatives related to utilization management and retrospective claims review.


Key Responsibilities

Clinical Review & Medical Necessity Determinations

• Review post-service and retrospective claims for medical necessity, coding accuracy, contract compliance, and medical policy adherence.
• Analyze clinical documentation and supporting medical records to determine appropriateness of services rendered.
• Prepare and electronically present cases to Medical Directors for approval, denial, or medical necessity determinations.
• Ensure accurate and timely case completion while meeting required turnaround times.

Case Management & Coordination

• Triage and prioritize cases based on urgency and established service-level requirements.
• Identify potential quality-of-care concerns, treatment delays, or service issues and intervene appropriately.
• Refer cases to Case Management, Disease Management, Appeals & Grievances, and Quality departments when necessary.
• Communicate determinations to providers in accordance with state, federal, and accreditation requirements.

Compliance & Quality Improvement

• Maintain compliance with organizational policies, regulatory requirements, and accreditation standards.
• Assist in the development and implementation of standardized clinical review processes.
• Support continuous improvement initiatives related to retrospective claims review and utilization management activities.

Required Qualifications

• Active Registered Nurse (RN) License
• Strong clinical nursing background
• Ability to work independently with minimal supervision
• Strong computer proficiency
• Experience with medical necessity review and clinical determinations
• Excellent written and verbal communication skills

Preferred Qualifications

• Previous Post-Service Review experience
• Prior Authorization experience
• Case Management experience
• Utilization Review experience
• Managed Care experience
• Experience working with Medical Directors on clinical determinations

Technical Skills

• Microsoft Word
• Basic Microsoft Excel
• Internet Research/Search Tools
• Electronic Medical Record (EMR) Systems

Team Environment

• Team Size: 14
• Fully Remote Position
• Standard Laptop Equipment Provide