Clinical Review Nurse RN
Location: Jacksonville, FL
Job Type: Direct Placement
Company: ARC Group
Category: Administration
Job Description Apply Now
Clinical Review Nurse RN
Are you a Registered Nurse (RN) seeking a rewarding opportunity to apply your clinical expertise in a non-bedside capacity? Join ARC Group as a Clinical Review Nurse RN, where you can utilize your nursing background to make impactful decisions about health claims, medical necessity, and quality of care—all while working remotely. ARC Group, a Forbes-ranked top 20 recruiting and executive search firm, is dedicated to diversity, equity, and inclusion, and seeks talented professionals who are passionate about improving healthcare delivery and ensuring compliance with national and local policies. As a Clinical Review Nurse RN, you will play a pivotal role in promoting high standards of patient care and supporting both providers and payers in navigating the complexities of healthcare claims and regulations.
Our remote Clinical Review Nurse RN roles are direct hire, full-time positions, offering competitive salary and comprehensive benefits. ARC Group values the diverse perspectives of our team members and actively fosters an environment where every individual is respected and empowered to contribute their best. If you are seeking a dynamic opportunity to advance your nursing career beyond traditional clinical settings, we encourage you to apply today by clicking the job application button.
As a Clinical Review Nurse RN at ARC Group, your primary responsibility will be to review and evaluate healthcare claims for medical necessity, appropriateness, and compliance with established standards of care. Your expertise will ensure accurate claims processing and support the identification of potential fraud, abuse, or practice concerns, making you a key contributor to the integrity and quality of healthcare services.
ARC Group is committed to providing equal employment opportunities and fostering an inclusive work environment. We welcome applications from qualified individuals of all backgrounds. If you require accommodation during any part of the recruitment process, please let us know. This position is offered with no fee to candidates.
Clinical Review Nurse RN - Summary- Apply clinical nursing expertise to review, analyze, and make determinations on healthcare claims.
- Ensure compliance with national and local medical policies and standards of care.
- Work remotely, contributing to a diverse and inclusive team dedicated to healthcare excellence.
- Support ARC Group's mission of integrity, quality, and shared success within the healthcare sector.
- Perform clinical review of pre- and post-payment healthcare claims, including prior authorization cases.
- Interpret and apply Centers for Medicare & Medicaid Services (CMS) guidelines to complex medical situations.
- Assess claim data and medical records for medical necessity, utilization, and appropriateness of care.
- Identify provider practices that may require corrective action, including potential fraud, abuse, or overpayment.
- Develop and communicate recommendations for corrective actions based on review findings.
- Process claims and complete project work using the appropriate computer systems and software (e.g., Microsoft Office Suite).
- Educate providers individually or in groups about medical review outcomes and requirements.
- Create written teaching materials and participate in provider training initiatives as needed.
- Collaborate with CMS leaders and provider community leaders to ensure effective communication and education.
- Participate in special projects as assigned, supporting the overall goals of the review department.
- Competitive salary with comprehensive benefits package.
- Direct hire, full-time position with ARC Group.
- Remote work environment supporting work-life balance.
- Opportunities for career advancement and professional growth within a leading healthcare organization.
- Valid, unrestricted Registered Nurse (RN) license.
- Degree in nursing from an accredited institution.
- Minimum of 2 years of clinical experience in a healthcare setting.
- Experience evaluating medical and healthcare delivery issues (e.g., Inpatient Rehab Facility).
- Excellent written and verbal communication skills.
- Proficiency with computers and Microsoft Office applications.
- Permanent US work authorization required.
- Holds a Bachelor of Science in Nursing (BSN) (preferred).
- Previous experience in Inpatient Rehabilitation Facility or insurance industry (preferred).
- Certified Coder certification is a plus.
- Detail-oriented with strong analytical and decision-making skills.
- Comfortable working independently in a remote setting while collaborating with a broader team.
- Committed to upholding the highest standards of ethics, integrity, and inclusivity.
- ARC Group is recognized for its commitment to diversity, equity, and inclusion in the workplace.
- Equal Employment Opportunity (EEO) statement: "At ARC Group, we are committed to providing equal employment opportunities and fostering an inclusive work environment. We encourage applications from all qualified individuals regardless of race, ethnicity, religion, gender identity, sexual orientation, age, disability, or any other protected status. If you require accommodations during the recruitment process, please let us know."
- No candidate fees apply for this position.
If you are eager to take your nursing expertise to the next level and contribute to the integrity of healthcare delivery, apply now by clicking the job application button and begin your journey as a Clinical Review Nurse RN with ARC Group.