Clinical Review Nurse RN
Location: Jacksonville, FL
Job Type: Direct Placement
Company: ARC Group
Category: Administration
Job Description Apply Now
Clinical Review Nurse RN positions are now open with ARC Group, an industry leader in recruiting top healthcare professionals nationwide. These full-time, remote opportunities offer experienced Registered Nurses (RNs) the chance to utilize their clinical expertise in medical claims assessment, healthcare compliance, and provider education. As a Clinical Review Nurse RN, you will play a vital role in ensuring that health claims are accurately reviewed for medical necessity, adherence to policy, and compliance with accepted standards of care. This position is ideal for RNs seeking to apply their clinical knowledge in a non-bedside setting while contributing to the integrity and quality of healthcare delivery.
ARC Group is dedicated to building a diverse and inclusive workforce. We value every team member and are committed to fostering an environment where all perspectives are respected. As a Clinical Review Nurse RN, you will join a dynamic team that supports professional growth and innovation. The remote work arrangement allows you to maintain flexibility while performing meaningful work that impacts patients, providers, and the healthcare system nationwide.
In this role, you will be responsible for reviewing healthcare claims, evaluating medical records, and determining the appropriateness of care. You will collaborate with healthcare providers, participate in special projects, and contribute to educational initiatives. The position also allows you to work on complex and varied assignments, offering continuous professional development. ARC Group is a Forbes-ranked, top 20 recruiting and executive search firm, recognized for its commitment to excellence and integrity in serving both candidates and clients.
Clinical Review Nurse RN - Summary- Remote, full-time opportunity with ARC Group for experienced Registered Nurses.
- Focus on clinical review of healthcare claims, policy adherence, and provider education.
- Work collaboratively with a diverse team in a supportive, innovation-driven environment.
- Contribute to healthcare compliance and quality improvement initiatives.
- Review and analyze pre- and post-pay complex healthcare claims from a medical perspective, including prior authorizations.
- Conduct comprehensive medical record reviews to assess coverage, medical necessity, utilization, and appropriateness of care based on national and local policies.
- Interpret and apply Centers for Medicare & Medicaid Services (CMS) guidelines to a wide variety of clinical scenarios.
- Identify provider practices that may require corrective action, including surfacing potential fraud, abuse, or practice concerns.
- Develop recommendations and participate in implementing corrective actions following medical review findings.
- Educate healthcare providers through written materials, one-on-one, or group sessions when required by medical review processes or appeals.
- Collaborate with CMS leaders and provider community representatives as needed.
- Complete assigned project work and process claims using appropriate computer systems.
- Participate in special projects and continuous professional development initiatives.
- Competitive salary commensurate with experience.
- Comprehensive benefits package available to full-time employees.
- Remote work flexibility for enhanced work-life balance.
- Career advancement potential within a respected, nationwide organization.
- Supportive, inclusive team culture focused on professional development and diversity.
- Valid unrestricted Registered Nurse (RN) license in the United States.
- Current permanent US work authorization required.
- Minimum of two years of recent clinical nursing experience.
- Strong written and oral communication skills.
- Demonstrated experience evaluating medical and healthcare delivery issues.
- Proficiency in Microsoft Office Suite and strong computer skills.
- Bachelor of Science in Nursing (BSN), inpatient rehabilitation facility experience, insurance industry experience, and coding certification are preferred but not required.
- Detail-oriented and analytical Registered Nurse who is passionate about healthcare quality and compliance.
- Comfortable working in a remote, independent setting while contributing to a team environment.
- Able to interpret complex healthcare guidelines and apply them accurately to individual cases.
- Excellent communicator, capable of providing clear education and feedback to healthcare providers.
- Experience in insurance, inpatient rehabilitation, or medical coding is a plus.
- ARC Group is committed to providing equal employment opportunities and fostering an inclusive work environment.
- No fees are charged to candidates for applying or placement.
- If you require accommodations during the recruitment process, ARC Group encourages you to inform the team for support.
- All qualified individuals are welcome to apply regardless of race, ethnicity, religion, gender identity, sexual orientation, age, disability, or any other protected status.
If you are a dedicated RN seeking a remote opportunity to make a difference in healthcare quality and compliance, apply now by clicking the job application button and take the next step in your nursing career with ARC Group!