Nurse Reviewer

Position Overview:

We are seeking a detail-oriented and clinically experienced Nurse Reviewer to join our healthcare claims review team. The Nurse Reviewer will be responsible for performing comprehensive reviews of facility and outpatient claims (pre- and post-payment), assessing alignment with medical documentation, clinical guidelines, coding accuracy, and policy compliance. The role is critical to ensuring billing accuracy, identifying overpayments, and generating cost savings for our clients.

This position requires clinical judgment, an understanding of billing and coding practices, and the ability to communicate effectively with healthcare providers and internal stakeholders. The Nurse Reviewer will manage a high-volume claim review workload, document findings thoroughly, and contribute to the quality and efficiency of the claim audit process.

Key Responsibilities:

• Conduct post-service, pre- or post-payment in-depth reviews across a variety of claim types.
• Apply medical guidelines, clinical criteria, plan exclusions, and coding standards to identify inaccuracies or overcharges.
• Validate billing charges against medical documentation to ensure compliance and accuracy.
• Contact medical providers via phone/email to discuss billing discrepancies and request additional information.
• Maintain detailed and accurate notes on claim review progress, communications, and outcomes.
• Manage and prioritize a caseload of 25+ claims based on client specifications and deadlines.
• Achieve and maintain production and quality metrics as established by the leadership team.
• Collaborate with Team Leads and escalate claim issues or client-specific needs as appropriate.
• Ensure compliance with internal standards and external privacy regulations (e.g., HIPAA).

Qualifications & Skills:

Required:

• Active and unrestricted RN or LPN license.
• Clinical experience in areas such as Medical-Surgical, ICU, or Emergency Medicine.
• Strong understanding of medical documentation, hospital coding, and billing rules.
• High attention to detail with a focus on accuracy and compliance.
• Excellent communication skills, both verbal and written.
• Proficient in Microsoft Office Suite (Outlook, Word, Excel).
• Skilled in basic math calculations and claim-related financial validation.
• Ability to handle multiple tasks simultaneously in a fast-paced environment.
• Comfortable working with dual-screen setups and extended periods of computer usage.

Preferred:

• Experience in claims auditing, medical billing, or revenue cycle management.
• Working knowledge of Medicare guidelines, health insurance policies, and payer programs.
• Familiarity with audit techniques and identification of claim-level revenue opportunities.

Job Type: Full-time

Pay: From ₹15,000.00 per month

Work Location: In person