IDR Nurse Reviewer (Healthcare)

TL;DR

IDR Nurse Reviewer (Healthcare): Conducting reviews and determinations for independent dispute resolutions (IDR) at Federal and State levels with an accent on medical record analysis and regulatory compliance. Focus on resolving claim disputes between providers and payers, ensuring robust clinical rationale, and performing quality assurance on determinations.

Location: Remote (Must hold a non-restricted nursing license in any US state)

Salary: $94,000–$115,000

Company

Data-centric healthcare transformation company focusing on elevating health outcomes through technology and clinical expertise.

What you will do

• Conduct initial assessments of medical documentation and identify missing records to resolve disputes.
• Perform clinical reviews and determinations for independent dispute resolutions (IDR) at Federal and State levels.
• Collaborate with legal teams, medical coders, and physicians to facilitate the resolution of disputes.
• Draft professional determination correspondence and provide robust clinical rationales for decisions.
• Perform quality assurance checks and audit patient records to ensure compliance with Federal or State guidance.
• Stay current with regulatory changes and conduct research on a case-by-case basis.

Requirements

• Active RN license (non-restricted) in any US state.
• Minimum 5 years of full-time equivalent experience providing direct care to patients.
• Strong oral and written communication skills in English for professional correspondence.
• Ability to analyze clinical documentation and apply appropriate guidelines.
• Proficiency with electronic documents (PDFs) and Microsoft Office Suite (Excel, Word, Outlook).
• Ability to manage sensitive and confidential information.

Nice to have

• Medical Coding Certification.
• Experience with Utilization Review.
• Knowledge of CPT coding and Explanation of Benefits (EOB).
• Previous experience with appeal and claim dispute processes.
• Familiarity with SharePoint or ShareFile.

Culture & Benefits

• Fully remote work arrangement.
• Culture driven by purpose, straightforward communication, and clinical domain expertise.
• Interdisciplinary team environment focused on achieving positive health outcomes.
• Equal employment opportunity employer with merit-based personnel processes.