Clinical Review Nurse; RN

ARC Group is seeking dedicated and detail-oriented professionals for the position of Clinical Review Nurse (RN). This role is available on a full-time, remote basis and offers an exceptional opportunity to be part of a dynamic and highly respected organization committed to upholding national and local medical standards of care. As a Clinical Review Nurse (RN), you will be an integral part of a collaborative team that focuses on analyzing healthcare claims, ensuring compliance with medical policies, and promoting appropriate patient care.

The position is structured to provide career growth and development while supporting an inclusive and diverse environment. ARC Group is proud to foster a workplace where every employee feels valued and respected, and where unique perspectives fuel innovation and progress. Professionals with a valid, unrestricted Registered Nurse license and a passion for making informed clinical decisions are encouraged to apply for this remote opportunity.

Candidates must have permanent US work authorization to be considered.

The Clinical Review Nurse (RN) is responsible for conducting thorough reviews of healthcare claims, assessing the medical necessity, appropriateness, and level of care based on national and local standards, and supporting claims adjudication. The primary focus is on the review and analysis of pre-payment and post-payment healthcare claims, including prior authorizations and complex medical cases. The Clinical Review Nurse (RN) applies clinical expertise to ensure claims meet established medical guidelines and may also contribute to provider education initiatives and special projects.

This position is designed for professionals who are adept at interpreting CMS guidelines and are committed to maintaining high standards of patient care through diligent review processes.

• Review and analyze complex healthcare claims, including pre-payment and post-payment scenarios, from a medical perspective, ensuring alignment with established policies and accepted standards of care.
• Perform clinical review work as assigned, providing guidance to team members and interpreting broad CMS guidelines to address specific, highly variable situations.
• Evaluate claim data and medical records to make informed clinical decisions regarding coverage, medical necessity, utilization, and appropriateness of care.
• Identify provider practices requiring corrective action, surfacing potential issues such as over payment, fraud, abuse, or concerns related to medical review findings.
• Develop recommendations for corrective action and, when applicable, refer cases for further review or implement necessary actions based on findings.
• Process claims and accurately complete project work using appropriate computer systems.
• Initiate or participate in provider teaching activities, including creating written educational materials and delivering one-on-one or group education sessions as a result of medical review or appeal processes.
• Participate in special projects and collaborate with CMS leaders and provider community leaders as required by assignment.

• Competitive salary commensurate with experience and qualifications.
• Comprehensive benefits package available to full-time employees.
• Direct hire, full-time employment status.
• Opportunities for long-term career advancement and professional development.
• Supportive and inclusive workplace culture that values diversity and innovation.

• Valid nursing degree from an accredited institution.
• Minimum of two years of clinical experience in a healthcare setting.
• Active, unrestricted Registered Nurse (RN) license.
• Proficiency in evaluating medical and healthcare…