About the position The Clinical Claims Reviewer, RN is responsible for performing utilization management (UM) reviews within the scope of nursing licensure for provider post-payment inquiries, reconsiderations, and authorization reviews. This role conducts comprehensive medical necessity reviews for inpatient, outpatient, concurrent, retrospective, pre-payment, and post-payment cases while ensuring compliance with regulatory requirements, health plan policies, and established clinical guidelines. Responsibilities • Perform utilization management reviews to determine medical necessity for pre-payment and post-payment reconsiderations and authorization requests. • Review inpatient, outpatient, concurrent, retrospective, and referral cases using established clinical criteria and health plan policies. • Evaluate member eligibility, benefits, and coverage guidelines when making review determinations. • Apply MCG, CMS, DMAS, health plan, and vendor-specific criteria to support clinical decision-making. • Identify cases requiring escalation and refer complex reviews to Medical Directors as appropriate. • Ensure compliance with regulatory and accreditation standards, including NCQA, CMS, DMAS, and Bureau of Insurance (BOI) requirements. • Document review findings accurately and maintain detailed case records. • Prepare and issue line-of-business-specific written determinations and notifications to providers. • Maintain productivity and quality standards while meeting departmental turnaround times. • Support audit readiness and participate in quality improvement initiatives Requirements • Active, unrestricted Registered Nurse (RN) license in the Commonwealth of Virginia. • Minimum of 3 years of acute care nursing experience. • Strong clinical assessment and critical-thinking skills. • Knowledge of medical necessity review processes and utilization management principles. • Experience interpreting clinical documentation and applying evidence-based criteria. • Excellent written and verbal communication skills. • Strong organizational skills with the ability to manage multiple priorities in a deadline-driven environment. • Proficiency with electronic medical records and healthcare systems Benefits • Medical, dental & vision • Critical Illness, Accident, and Hospital • 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available • Life Insurance (Voluntary Life & AD&D for the employee and dependents) • Short and long-term disability • Health Spending Account (HSA) • Transportation benefits • Employee Assistance Program • Time Off/Leave (PTO, Vacation or Sick Leave)
TEKsystems is an IT staffing and services firm providing workforce solutions and placing professionals across technology and related fields, including clinical and healthcare staffing.
