Job Title: Registered Nurse – Medical Claims Reviewer (FES Claims)
Duration: 13 Weeks
Schedule: 8-hour shifts | 8:00 AM – 05.00 PM | No Weekends
Location: REMOTE (Willingness to attend 1–2 onsite training sessions if required)
Must Have: Access to a personal laptop (remote desktop access will be provided)
Certifications Required:
Active RN License (Arizona)
Basic Life Support (BLS)
Fingerprint Clearance Card (must be obtained before start)
Job Summary:
We are seeking a highly motivated and detail-oriented Registered Nurse to serve as a Medical Claims Reviewer for FES 1500 claims. This position involves evaluating emergency medical claims to ensure accuracy, compliance with standards, and appropriate reimbursement practices. Candidates must be capable of working remotely with a high level of independence and discretion.
Key Responsibilities:
Conduct thorough reviews and adjudication of FES 1500 claims in line with standard industry guidelines
Evaluate claims for emergency criteria, medical necessity, correct coding, length of stay, and level of care
Collaborate with providers for second-level review when required
Analyze claims data for reporting, trend identification, and savings tracking
Participate in special projects and conduct research when assigned
Apply InterQual criteria, CCI edits, and relevant regulations during claim assessments
Required Knowledge & Competencies:
Strong foundation in nursing practice, utilization review, and case management
Proficiency in CPT, HCPCS, ICD-9 (ICD-10 preferred) coding systems
Ability to assess medical documentation to determine appropriate care levels
Knowledge of managed care protocols, InterQual Criteria, and CCI edits
Understanding of AHCCCS and CMS regulatory requirements
Competent in data entry and statistical analysis
Independent worker with strong collaboration and communication skills
Additional Requirements:
Access to a personal laptop (remote desktop access will be provided)
High school diploma or equivalent