Clinical Review Nurse RN
Location: Jacksonville, GA
Job Type: Direct Placement
Company: ARC Group
Category: Administration
Job Description Apply Now
Clinical Review Nurse RN positions are now available for qualified and experienced nursing professionals seeking a rewarding remote opportunity. This full-time role enables Registered Nurses to leverage their clinical expertise in reviewing healthcare claims, ensuring compliance with medical standards, and supporting healthcare quality for patients across the region. As a Clinical Review Nurse RN, you will be at the forefront of healthcare claims review, making a meaningful impact by upholding national and local healthcare policies while promoting optimal patient care outcomes.
As a Clinical Review Nurse RN, you will be a pivotal member of a respected organization committed to diversity, equity, and inclusion. The company values diverse perspectives and welcomes applicants from all backgrounds. This is a 100% remote, full-time position designed for residents with permanent U.S. work authorization. The role is ideal for registered nurses who are passionate about clinical excellence, meticulous in documentation, and eager to work in a supportive and innovative environment. If you are dedicated to using your nursing skills in a non-traditional, analytical capacity and ready to advance your career, this opportunity is for you.
Working as a Clinical Review Nurse RN offers the flexibility of remote work while engaging in impactful duties such as medical claims analysis, provider education, and healthcare compliance. The position is structured to provide significant career growth opportunities within a dynamic, mission-driven organization that prioritizes employee development and fosters a culture of respect and collaboration. Candidates who enjoy problem-solving, continuous learning, and interdisciplinary teamwork will find this role particularly fulfilling.
Clinical Review Nurse RN - Summary- Conduct comprehensive reviews of healthcare claims, ensuring alignment with national and local policies.
- Apply clinical expertise to assess the medical necessity, appropriateness of care, service levels, and validity of claims for a wide range of medical services.
- Support organizational goals for healthcare quality and cost-effectiveness by making informed determinations on claims and authorizations.
- Engage in both individual and collaborative projects to enhance healthcare delivery and claims processing systems.
- Review and analyze pre- and post-payment healthcare claims from a clinical perspective, including prior authorizations and complex cases.
- Examine claim data and medical records to determine coverage, medical necessity, utilization, and appropriateness of care according to established policies and accepted clinical standards.
- Identify and address issues related to overpayment, corrective action, potential fraud, or abuse, making recommendations for follow-up actions as needed.
- Process claims and complete project work efficiently in relevant electronic systems.
- Educate providers by delivering individual or group instruction based on medical review findings, supporting continuous improvement in provider practices.
- Participate in special projects, collaborating with internal leaders and provider communities to advance organizational initiatives and healthcare standards.
- Competitive salary commensurate with experience.
- Comprehensive benefits package, including health, dental, vision, and retirement options.
- Opportunities for professional development and career advancement within a respected, growth-oriented organization.
- Remote work flexibility supporting work-life balance.
- Valid nursing degree from an accredited institution.
- Minimum of 2 years direct clinical experience in a healthcare setting.
- Current, unrestricted Registered Nurse (RN) license.
- Proficient in Microsoft Office and electronic health record systems.
- Strong written and verbal communication skills, with the ability to clearly convey complex clinical information.
- Experience evaluating medical and healthcare delivery issues, such as in Inpatient Rehabilitation Facilities, is highly valued.
- Permanent U.S. work authorization required.
- Detail-oriented and analytical, with a strong commitment to clinical accuracy and compliance.
- Proactive in identifying areas of improvement and educating healthcare providers.
- Adaptable to dynamic workflows in a remote work setting.
- Demonstrated ability to collaborate with interdisciplinary teams and manage multiple priorities effectively.
- Preferred qualifications include a Bachelor of Science in Nursing (BSN), experience in Inpatient Rehabilitation Facilities, insurance industry experience, or Certified Coder credentials.
- This role is offered as a direct hire, remote position for qualified candidates with appropriate licensure and experience.
- The organization is dedicated to equal employment opportunity and encourages applications from candidates of all backgrounds and experiences.
- Advance your career as a Clinical Review Nurse RN and contribute to a mission-driven organization focused on healthcare excellence by applying now through the job application button.
Take the next step in your nursing career—apply today for the Clinical Review Nurse RN position and become part of a team dedicated to making a positive impact in healthcare. Click the job application button to submit your application.