Job Description
Registered Nurse RN or LVN– Retrospective Claims Review
Location: Remote (California RN or LVN license required)
Employment Type: Contract to permanent hire.
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 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
Familiarity with MCG
Familiarity with Division of Financial Responsibility (DOFR) guidelines and their application in utilization management and authorization review.
Proficiency with claims systems (e.g., Facets, QNXT, or similar platforms)
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?
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
