Remote Registered Nurse – 252506 – New York

Registered Nurse – Clinical Review Specialist (IDR/Appeals)

Position Overview

We are seeking an experienced Registered Nurse to support the review and resolution of State and Federal Independent Dispute Resolution (IDR) cases. This role is responsible for conducting detailed clinical reviews, evaluating prior authorizations and disputed claims, and collaborating with interdisciplinary teams to ensure accurate and compliant determinations.

Key Responsibilities

• Perform comprehensive clinical reviews for disputed claims, prior authorizations, and appeal cases.
• Analyze medical records, supporting documentation, payer guidelines, and regulatory requirements to develop case determinations.
• Complete electronic review tools, maintain accurate case documentation, and prepare final recommendations.
• Assist with claim evaluations and adjudication activities related to reimbursement disputes.
• Collaborate closely with physicians, clinical reviewers, analysts, and administrative staff throughout the review process.
• Serve as a subject matter resource by providing guidance, troubleshooting support, and clarification on case determinations.
• Participate in team meetings, workflow discussions, and educational sessions to promote consistency and quality outcomes.
• Support onboarding and mentorship efforts for newly hired nursing staff as the program continues to grow.
• Contribute to process improvement initiatives and additional projects as assigned.

Qualifications

• Active Registered Nurse (RN) license required.
• Bachelor’s Degree in Nursing (BSN) required.
• Minimum of two years of clinical nursing experience required.
• Experience working with electronic medical records (EMR) systems.
• Strong analytical, critical thinking, and problem-solving skills.
• Excellent written and verbal communication abilities.
• Ability to work independently while managing multiple priorities in a fast-paced environment.
• Demonstrated ability to collaborate effectively with clinical and non-clinical teams.
• Flexible, adaptable, and committed to delivering high-quality outcomes.

Schedule

• Monday through Friday
• Standard business hours: 9:00 AM – 5:00 PM
• Some schedule flexibility available based on business needs
• Full-time, 40 hours per week