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