RN – Medical Claims Reviewer

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🕒 3 days ago

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Simsy Ventures

WebsiteLinkedInAll Job Openings

11 - 50 employees

Founded 2022

🤝 B2B

B2B • Startup • Sustainability

Simsy Ventures is a venture builder and institutional co-founder that partners with entrepreneurs, investors, and corporations to create sustainable startups. Their mission focuses on enabling startups to achieve true potential while promoting a positive impact on profits, people, and the planet. With a structured approach, they support startups throughout their lifecycle, from ideation to market validation and growth. By leveraging a repeatable venture studio model, Simsy Ventures aims to uplift economies globally through impactful entrepreneurship.

📋 Description

• Conducting pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines • 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 • Provide guidance to LPN team members and support non-clinical staff through training and discussions • Assist with special projects and additional responsibilities as assigned

🎯 Requirements

• 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 Home Health, Utilization/Medical Review, or Quality Assurance • Strong clinical background in managed care, home health, rehabilitation, and/or medical-surgical settings • Ability to interpret and apply medical review criteria and clinical guidelines • Proficiency in Microsoft Office and word processing software • Excellent customer service, communication, and critical thinking skills

🏖️ Benefits

• Remote (U.S. – Work from home) • High-speed internet (non-satellite) • Private, lockable home office • All necessary equipment provided