Claims Review Nurse

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⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $75k - $85k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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The NAI

WebsiteLinkedInAll Job Openings

1 - 10 employees

Founded 2000

💼 Consulting

📣 Marketing

📱 Media

Consulting • Marketing • Media

The NAI is the Network Advertising Initiative, a self-regulatory trade association for the digital advertising and ad tech industry focused on responsible data collection and consumer privacy. It develops privacy principles and a self-regulatory framework, conducts privacy reviews and guidance, publishes policy comments and educational resources (e. g. , on privacy-enhancing technologies), and advocates on digital advertising and privacy policy while supporting member compliance and opt-out mechanisms.

📋 Description

• Conduct initial assessments of documentation from initiating and responding parties • Review submissions, identify missing documents, and determine requirements for dispute resolution • Obtain appropriate documentation according to established procedures • Determine the appropriate clinical reviewer, such as a medical coder or physician • Prepare case documents and provide instructions to assigned clinical reviewers • Collaborate with the legal team to resolve disputes • Draft professional determination letters • Communicate with enrollees, health plans, and providers as needed • Deliver determinations within required timelines • Apply CPT code knowledge • Participate in required meetings • Collaborate with credentialed clinical professionals to determine medical necessity • Use governmental and professional guidelines to assess appropriateness of services and procedures • Adhere to company policies, state regulations, and project guidelines • Complete reviews within assigned deadlines and follow QA/QC processes • Uphold scheduling commitments and privacy regulations • Perform other related duties as directed by leadership

🎯 Requirements

• Maintain an active license in nursing • Five years of full-time equivalent experience providing direct care to patients • Hold a non-restricted nursing license in any state in the US • Knowledge of claim review processes including billing, Current Procedural Terminology (CPT) coding, and Explanation of Benefits • Familiarization with electronic documents such as PDFs, Microsoft Excel, Microsoft Word, and Microsoft Outlook • Familiarization with electronic data repositories such as SharePoint and/or ShareFile • Exceptional skills in managing sensitive and confidential information • Strong organizational, written, and verbal communication skills in English • Ability to work independently and collaboratively with clinical reviewers, physicians, and attorneys • Skilled in prioritizing tasks according to business needs and assignments • Appeal and/or claim dispute-related experience preferred • Successful completion of a background check is required