Virginia Licensed Nurse Reviewer

To support healthcare quality assurance, the full-time Sr. Nurse Reviewer (Medicare) will perform complex medical record reviews of Medicare claims remotely, utilizing clinical judgment to assess overpayment potential and compliance with established guidelines. Key Responsibilities Perform complex medical record reviews requiring clinical judgment on Medicare Part A/B and DMEPOS claims Determine coverage, medical necessity, and appropriateness of services against NCDs, LCDs, and CMS coverage/payment policy Document clear, defensible rationale for payment or denial recommendations Required Qualifications Graduation from an accredited school of nursing with current, unrestricted licensure as a Registered Nurse (RN) 2-4 years of clinical experience with demonstrated ability to apply clinical judgment to medical necessity and coverage determinations Detail-oriented with strong knowledge of medical terminology and clinical documentation standards Associate's degree (or accredited nursing diploma) in a healthcare-related field Experience in medical/claims review, including pre- and post-payment claims reviews