Medical Review Nurse

Join to apply for the Medical Review Nurse role at SCAN.

SCAN Group is a not‑for‑profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN is the sole corporate member of SCAN Health Plan, one of the nation’s leading not‑for‑profit Medicare Advantage plans serving more than 300,000 members across the western United States. With over 45 years of experience, SCAN is a respected leader in senior healthcare and offers talented professionals a supportive environment with training, growth opportunities and state‑of‑the‑art tools.

• Review and analyze pre‑ and post‑payment of complex health‑care claims from a medical perspective.
• Perform audits/reviews of medical claims per established criteria, identify the need for medical record review and necessary documentation to support the decision‑making process regarding appropriateness of claim, billed charges and benefit coverages.
• Provide guidance to other staff members and accurately interpret and apply broad Centers for Medicare and Medicaid Services (CMS) guidelines to specific and highly variable situations.
• Conduct review of claims data and medical records to make clinical decisions on coverage, medical necessity, utilization and appropriateness of care per national and local policies as well as accepted medical standards of care.
• Process workload and complete project work in the appropriate computer system(s); contribute to team effort by accomplishing related results as needed.
• Route identified clinical and/or risk issues to appropriate personnel such as Medical Director, Quality of Care (QOC) Nurse, Medical Management Specialist, Member Services, etc.
• Review/prepare potential claim denials in conjunction with Medical Director.
• Collaborate with Medical Director on adjudication of claims and post‑service appeals.
• Participate in special projects, work groups and committees (e.g., interdisciplinary work groups, report analysis, independent review entity (IRE), etc.) as assigned.
• Actively support the achievement of SCAN’s Vision and Goals.
• Perform other duties as assigned.

• Associate's Degree or equivalent experience required.
• Current and active California RN License in good standing required.
• Bachelor's Degree or equivalent experience preferred.
• Certified Professional Coder preferred.
• 3–5 years of related experience in clinical decision‑making relative to Medicare patients.
• Certifications deemed reasonable to function at this level.
• Performs work under minimal supervision.
• Handles complex issues and problems and refers only the most complex issues to higher‑level staff.
• Possesses comprehensive knowledge of subject matter.
• Technical expertise – strong technical skills for functional area.
• Problem‑solving – strong problem‑solving skills.
• Communication – good communication and interpersonal skills.
• Ability to work as part of a team.
• Oral and written communication skills.
• Attentiveness.
• Interpersonal skills.

• Base salary range: $38.61 to $49.8 per hour.
• Remote position.
• Annual employee bonus program.
• Robust wellness program.
• Generous paid‑time‑off (PTO).
• Eleven paid holidays per year, plus one floating holiday and one birthday holiday.
• Excellent 401(k) retirement saving plan with employer match and contribution.
• Robust employee recognition program.
• Tuition reimbursement.
• Opportunity to become part of a team that makes a difference to our members and community every day.

At SCAN we believe that it is our business to improve the state of our world. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits and more. SCAN is proud to be an Equal Employment Opportunity and affirmative action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, marital status, disability, protected veteran status or any other status protected by law.

A background check is required.

We’re always looking for talented people to join our team! Qualified applicants are encouraged to apply now.