Job Title: Registered Nurse – Medical Claims Reviewer (FES Claims)
Location: Remote (Must reside in or near Phoenix, AZ 85034)
Duration: 13 Weeks
Schedule: Monday–Friday | 8:00 AM – 5:00 PM | No Weekends
Equipment Requirement: Personal laptop (remote desktop access will be provided)
Active Registered Nurse (RN) License – Arizona
Basic Life Support (BLS) Certification
Fingerprint Clearance Card (must be obtained prior to start)
We are seeking a detail-oriented and self-driven Registered Nurse to join our team as a Medical Claims Reviewer specializing in FES 1500 claims. This role is remote, but candidates must be located in the Phoenix, AZ area. The ideal candidate will have strong clinical knowledge, experience in utilization review, and a deep understanding of emergency care criteria and medical coding standards.
Review and adjudicate FES 1500 emergency medical claims according to established guidelines
Evaluate claims for medical necessity, emergency status, proper coding, length of stay, and level of care
Conduct second-level reviews and provider collaboration as needed
Analyze claims data to identify trends, generate reports, and track savings
Participate in special projects and conduct related research
Apply InterQual criteria, Correct Coding Initiative (CCI) edits, and current regulations during evaluations
In-depth clinical nursing knowledge with experience in utilization review and case management
Proficiency in CPT, HCPCS, ICD-9/10 coding systems
Ability to interpret medical records and assess appropriate levels of care
Familiarity with managed care protocols, InterQual Criteria, and CCI edits
Knowledge of AHCCCS and CMS regulations
Strong skills in data entry, organization, and trend analysis
Independent, self-motivated, and comfortable working remotely
Excellent communication and collaboration skills
Active RN License (Arizona)
BLS Certification
Fingerprint Clearance Card (prior to start date)
Personal laptop for remote access
High school diploma or equivalent