Remote Post-Service Clinical Nurse (RN) – California

Title: Post-Service Clinical Review Nurse (RN)

Location: Remote – Must Reside in California

Type: Full-Time Contract

We are seeking an experienced Clinical Review Nurse (RN) to support a high-impact retrospective claims review program. This role is responsible for evaluating medical claims and records to ensure services align with clinical guidelines, medical necessity, and reimbursement policies.

This position is ideal for nurses with experience in post-service review, utilization management, or prior authorization, who are comfortable working in a fast-paced, production-driven environment.

Key Responsibilities:

• Perform retrospective clinical claim reviews and make initial determinations using evidence-based guidelines
• Evaluate claims for medical necessity, coding accuracy, and policy compliance
• Review outpatient services including DME, radiology, labs, and genetic testing
• Prepare cases for Medical Director review when needed and communicate determinations
• Ensure documentation meets regulatory and accreditation standards
• Prioritize workload to meet strict turnaround times
• Identify quality of care concerns and escalate appropriately
• Collaborate with claims, appeals, and care management teams

Requirements:

• Active California RN license (required)
• Experience in post-service review, prior authorization, or outpatient claims review
• Strong knowledge of CPT, ICD-10, HCPCS coding and billing practices
• Ability to work independently and apply clinical judgment
• Experience in a fast-paced, production-based environment

Nice to Have:

• Experience with retrospective claims review programs
• Background in utilization management or case management
• Experience reviewing a wide range of outpatient services