Medical Reviewer, Registered Nurse

Job Description:

  • Review and interpret medical records and clinical documentation to determine medical necessity and appropriateness of healthcare services
  • Provide clinical review support for Treatment Authorization Requests (TARs) and other authorization activities
  • Support medical review activities related to medical policy, claim adjudication, drug utilization review, and other healthcare program requirements
  • Apply professional nursing principles, clinical judgment, medical policies, and established utilization guidelines when completing reviews
  • Review documentation to determine whether requested services, procedures, supplies, and equipment meet coverage and clinical requirements
  • Document review findings, decisions, and supporting clinical rationale accurately and timely
  • Determine approvals within established guidelines or refer cases to physicians or other appropriate clinical professionals
  • Apply knowledge of hospital routines, medical services, medical supplies, and appropriate clinical uses
  • Collaborate with physicians, pharmacists, nurses, and other healthcare professionals
  • Maintain current knowledge of clinical criteria, medical policies, procedures, and regulatory requirements
  • Meet established quality, accuracy, productivity, and turnaround-time standards
  • Work primarily from a home office supporting Medical Review Services for California healthcare programs
  • Navigate multiple systems and applications to complete reviews and document findings

Requirements:

  • Active and unrestricted Registered Nurse (RN) license to practice in the State of California, in good standing
  • Minimum of two (2) years of professional nursing experience
  • Possession of a Master’s Degree in Nursing may substitute for one (1) year of the required professional nursing experience
  • Knowledge of professional nursing principles and techniques, hospital routines, and medical supplies and their uses
  • Training and/or certification in wound and ostomy care preferred
  • Strong clinical judgment and ability to interpret medical records and supporting clinical documentation
  • Experience with medical review, utilization review, medical necessity review, prior authorization, Treatment Authorization Requests (TARs), or claims review preferred
  • Strong written and verbal communication skills
  • Ability to navigate multiple computer systems and applications
  • Ability to maintain required professional licenses, certifications, and credentials in active, unrestricted, and good-standing status

Benefits:

  • Flexible hours
  • Work-life balance
  • Continuous learning and career development
  • Flexible vacation policy
  • 401(k) employer match
  • Comprehensive health benefits
  • Educational assistance
  • Leadership and technical development academies
  • Ongoing training and support
Back to blog

Other Jobs To Apply

Hobby Lobby New Job Openings $30/Hour

Eddie Bauer Work From Home Jobs (Customer Support) $75000/Year

Manager, GTM - UCANZ (Contract)

Remote Account Support Specialist – Hulu Subscriber Retention & Escalation

[Remote] Senior Consultant, Account Services Management - Plano, Texas

Customer Service Rep (100% Work From Home)

Inside Sales Representative (Remote - Western Region)

Data Entry

Sr Patient Accounting Representative, Full Time, First Shift, Remote

Customer Service Representative - Lab (Remote)

Remote Jobs Wells Fargo, Wells Fargo Jobs Remote – Job ID- 403 Job ID- 2576

Aetna Cvs Work From Home

SAP MDG Enterprise Asset Management Functional Consultant Remote / Telecommute Jobs

ServiceNow Functional Lead 102420 Remote / Telecommute Jobs

Virtual Performance Integration Manager - GM Defense

REMOTE: Insurance Sales Representative

Virtual Health Technician II

English Screener

Clinical Application Specialist - Digital Implementation Services

Incident Response Consultant (Remote)

Staff Embedded Software Engineer, Virtualization

Field Medical Advisor, Oncology

Manager, Training Delivery (Remote)

Director, Creator & Affiliate Marketing

Senior AI Solutions Architect (RapidScale) (Remote)

Security Consulting Engineer(Remote)

Supervisor Employee Services Contact Center - REMOTE

Bilingual Spanish Part Time Retail Sales Consultant

Lead Strategist Project Based

Account Executive, SMB Team Sales - Miami, FL

[Remote] Senior Data Product Manager, CMC Digital

US Director of Medical Affairs (US DMA) – Infectious Diseases and Vaccines (Respiratory), Remote

Senior Product Service Specialist - Water Heaters (Remote - US Only - Must Reside in the Central ...

Lead Graphic Designer, Accessories (Remote)

Boeing Virtual Information Session - Fall 2026 [Remote]

Remote Operator (Spring, TX)

Marcus by Goldman Sachs, Complaints Specialist, Richardson, TX/Draper, UT

Staff Software Engineer at Block, Inc.: 100% Remote (New York, NY)

Community College Veterans Information Session with Bank of America

Principal Technical Writer - Customer Onboarding

CONFIGURATION SPECIALIST(MONDAY.COM)

Azure and GitHub Consultant

Finance Manager, Marketing

Amex Work From Home Jobs

Work From Home Jobs At Walmart $24/Hour

The Walt Disney Company is hiring: Remote Spanish Sports Video Content Creator i

Junior/Mid AI Video Artist (Full Remote - Worldwide)

Data Entry Clerk Work From Home - Part-Time Focus Group Participants (Up To $750/Week)

Online Typing Jobs (Remote Position)

SE Region for CDL A Drivers. Top 50% Avg. $81,172