Claims Nurse (Utilization Management / Claims Review) Must have CALIFORNIA license
Registered Nurse RN or LVN– Retrospective Claims Review (Contract ends 12/31/26) Location: Remote (California RN or LVN license required) Employment Type: Temp/Full-Time Schedule: Mon-Friday 8am-5pm Pacific Standard Time Compensation: $100,000-$105,000 annually About the Opportunity We are partnering with a leading healthcare organization to identify a skilled Claims Review Nurse with deep experience in retrospective medical claims analysis. This is a temporary position that will go through December 31, 2026. This role is ideal for a clinically strong nurse who understands how to evaluate services after they’ve been rendered, ensuring accuracy, compliance, and appropriate reimbursement. This position plays a critical role in identifying discrepancies, preventing improper payments, and supporting high-quality, cost-effective care through detailed post-service review.
Key Responsibilities
- Conduct retrospective review of medical claims, including inpatient and outpatient services, to validate accuracy and appropriateness
- Analyze claims against clinical guidelines, medical necessity criteria, and reimbursement policies
- Review medical records, physician documentation, and billing data to support claim determinations
- Partner with claims operations, coding teams, and utilization management to resolve complex cases
- Identify patterns of overpayment, underpayment, or potential fraud/waste/abuse, and escalate as needed
- Provide clinical input on appeals, reconsiderations, and dispute resolutions
- Ensure adherence to federal/state regulations and industry standards (CMS, NCQA, etc.)
- Support audit initiatives and contribute to continuous process improvement efforts
- Educate internal stakeholders on documentation and clinical factors impacting claims outcomes
Required Qualifications
- Active, unrestricted RN or LVN/LPN license in California
- Minimum 2+ years of experience in clinical review, utilization management, or health plan operations
- Strong experience with retrospective claims review (this is a core requirement)
- Solid understanding of medical necessity criteria and post-service review processes
- Familiarity with ICD-10, CPT, and HCPCS coding
- Experience working with Medicare Advantage populations strongly preferred
- Proficiency with claims systems (e.g., Facets, QNXT, or similar platforms)
Key Skills
- Strong clinical judgment with the ability to apply it in a non-patient-facing, analytical setting
- High attention to detail and ability to interpret complex medical documentation
- Ability to translate clinical findings into clear claims decisions
- Effective collaboration and communication across multidisciplinary teams
- Organized, self-directed, and able to manage high-volume workloads
Why This Role
- Work remotely with a high-impact team
- Focus on analytical, retrospective review work rather than direct patient care
- Opportunity to influence payment integrity and healthcare quality outcomes
Job Type: Full-time Pay: $100,000.00 - $105,000.00 per year Benefits:
- 401(k) matching
- Dental insurance
- Disability insurance
- Employee assistance program
- Employee discount
- Flexible schedule
- Flexible spending account
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Parental leave
- Professional development assistance
- Referral program
- Retirement plan
- Travel reimbursement
- Vision insurance
Application Question(s):
- Have you performed DRG validation or DRG reviews for claims?
- Can you work Monday - Friday, 8am- 5pm PACIFIC hours?
- Are you comfortable with a TEMP position that will go through December 31. 2026?
Experience:
- CMS Medicare Guidelines: 1 year (Preferred)
- Retro Claims Review: 1 year (Required)
- Medicare: 1 year (Required)
License/Certification:
- Active California RN or LVN Licence (CA is NOT compact) (Required)
Work Location: Remote