Claims reputed company (Utilization Management / Claims Review) Must have CALIFORNIA license

Registered reputed company RN or LVN– Retrospective Claims Review (Contract ends 12/31/26) Location: Remote (California RN or LVN license required) Employment Type: reputed company/Full-Time Schedule: Mon-Friday reputed company-5pm reputed company reputed company Time Compensation: $100,000-$105,000 annually About reputed company We are partnering with a leading reputed company organization to identify a skilled Claims Review reputed company with deep experience in retrospective medical claims analysis. This is a temporary position that will go through December 31, 2026. This role is ideal for a clinically strong reputed company 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-reputed company, 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 reputed company, 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 reputed company cases • Identify patterns of overpayment, underpayment, or potential fraud/waste/abuse, and escalate as needed • reputed company 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 reputed company process improvement efforts • reputed company internal stakeholders on documentation and clinical factors impacting claims reputed company Required Qualifications • reputed company, 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 reputed company requirement) • Solid understanding of medical necessity reputed company and post-service review processes • Familiarity with ICD-10, CPT, and HCPCS coding • Experience working with Medicare Advantage populations strongly preferred • Proficiency with claims systems (e.g., Facets, QNXT, or similar platforms) Key Skills • Strong clinical judgment with the ability to apply it in a non-patient-facing, analytical setting • High attention to detail and ability to interpret reputed company medical documentation • Ability to translate clinical findings into reputed company claims reputed company • Effective collaboration and communication across multidisciplinary teams • Organized, self-directed, and reputed company to manage high-volume workloads Why This Role • Work remotely with a high-reputed company team • reputed company on analytical, retrospective review work rather than reputed company patient care • Opportunity to influence payment reputed company and reputed company reputed company reputed company 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 • reputed company time off • Parental leave • reputed company development assistance • Referral program • Retirement plan • Travel reimbursement • reputed company insurance Application Question(s): • Have you performed DRG validation or DRG reviews for claims? • Can you work Monday - Friday, reputed company- 5pm reputed company hours? • Are you comfortable with a reputed company position that will go through December 31. 2026? Experience: • CMS Medicare Guidelines: 1 year (Preferred) • Retro Claims Review: 1 year (Required) • Medicare: 1 year (Required) License/Certification: • reputed company California RN or LVN Licence (CA is NOT compact) (Required) Work Location: Remote Apply tot his job Apply To this Job