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Job Title: Clinical Review Nurse I
Location: Remote - Work From Home
Schedule: Monday through Friday, 8:30 AM - 5:00 PM
Job Summary:
We are seeking a detail-oriented and compassionate Clinical Review Nurse to join our team in a remote, full-time capacity. In this role, you will be responsible for conducting clinical reviews of medical claims to determine whether the services provided meet the benefit criteria of the member's health plan. The ideal candidate will use sound clinical judgment, adhere to medical policy, and ensure compliance with established guidelines to support appropriate and timely claims determinations.
Key Responsibilities:
Review and evaluate clinical information on submitted claims for medical necessity, appropriateness, and alignment with established medical policy and criteria.
Make determinations based on clinical judgment, policy guidelines, and benefit coverage.
Collaborate with physicians, providers, and other healthcare professionals as needed to gather additional information.
Document all decisions and clinical rationale clearly and accurately in the appropriate systems.
Ensure compliance with applicable regulatory standards and organizational policies.
Maintain current knowledge of medical guidelines and benefit structures.
Qualifications:
Required:
Associate's Degree in Nursing (ASN or ADN).
Minimum of 1 year of clinical experience (hospital, outpatient, or other direct patient care setting).
Current, unrestricted RN license in good standing in your state of residence.
Strong attention to detail, critical thinking, and decision-making skills.
Proficient in using computer systems and electronic documentation platforms.
Preferred:
Bachelor's Degree in Nursing (BSN).
Experience in medical claims review, utilization management, or case management.
Ability to interpret and apply medical policy, clinical criteria, and health plan benefits.
Strong written and verbal communication skills, with the ability to clearly articulate clinical decisions.
Additional Information:
Work Environment: 100% Remote - must have a reliable internet connection and appropriate home office setup.
Hours: Monday-Friday, 8:30 AM-5:00 PM (no weekends or holidays required).
Competitive compensation and benefits package available.
PME is an equal opportunity employer. We prohibit discrimination and harassment against any applicant or employee based on any legally recognized basis, including, but not limited to: veteran status, uniformed servicemember status, race, color, religion, sex, sexual orientation, gender identity, age (40 and over), pregnancy, national origin or ancestry, citizenship status, physical or mental disability, genetic information (including testing and characteristics) or any other category protected by federal, state or local law.
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Professional Management Enterprises
remote work
Jul 18, 2025