Chime is looking for a Remote RN – Medical Claims Reviewer to apply clinical expertise in ensuring compliance and appropriate reimbursement. In this role, you will conduct thorough medical reviews to uphold clinical criteria and guidelines for coverage determinations.
What You'll Do
- Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
- Assess payment determinations using clinical information and established guidelines.
- Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement.
- Provide clear, well-documented rationales for service approvals or denials.
- Educate internal and external teams on medical review processes, coverage determinations, and coding requirements.
- Support quality control activities to meet corporate and team objectives.
- Assist with special projects and additional responsibilities as assigned.
What We're Looking For
- Active, unrestricted RN license in the U.S. and in the state of hire OR Active compact multistate RN license.
- Associate Degree in Nursing OR Graduate of an accredited School of Nursing.
- Two years of clinical experience plus at least two years in one of the following: Inpatient/Outpatient settings, Utilization/Medical Review, or Quality Assurance.
- Strong clinical background in managed care and/or inpatient/outpatient settings.
- Ability to interpret and apply medical review criteria and clinical guidelines.
- Proficiency in Microsoft Office and word processing software.
- Strong analytical, organizational, and decision-making skills.
- Ability to work independently while managing priorities effectively.
- Excellent customer service, communication, and critical thinking skills.
- Ability to handle confidential information with discretion.
Nice to Have
- Three years of clinical nursing experience in Inpatient/Outpatient settings, Utilization Review, Medical Review, or Quality Assurance.
- Proficiency in using multiple screens and software programs simultaneously.
- Training and experience in ICD coding.
Technical Stack
- Microsoft Office
Work Mode
This is a fully remote position open to candidates located anywhere within the United States.
Broadway Ventures is an equal opportunity employer.
