Nurse Reviewer (Healthcare)

Location: Fully remote within the United States; for federal contract work, the nursing license must be issued by a United States licensing body.

Salary: $82,000–$95,000 per year

Company

hirify.global provides data-driven healthcare solutions that combine technology, clinical expertise, and quality-focused processes to improve care outcomes and efficiency.

What you will do

• Perform complex medical record reviews of Medicare Part A/B and DMEPOS claims requiring clinical judgment.
• Determine coverage, medical necessity, appropriateness of care, and payment validity using NCDs, LCDs, and CMS policies.
• Document clear, defensible rationale for payment and denial recommendations.
• Identify documentation patterns suggesting fraud, waste, abuse, or medical record alteration.
• Explain review rationale to providers and suppliers, support claim re-reviews, and participate in provider education.
• Maintain a 95% or higher accuracy score and participate in peer-review and inter-rater reliability activities.

Requirements

• Current, unrestricted Registered Nurse license is required; an active compact multistate RN license is acceptable.
• The license must be recognized in the jurisdiction relevant to the assigned work; federal contract work requires a license issued in the United States.
• 2–4 years of clinical experience applying clinical judgment to medical necessity, coverage, and appropriateness-of-care determinations.
• Experience with medical or claims review, including pre-payment, post-payment, or utilization review.
• Associate's degree or accredited nursing diploma in a healthcare-related field.
• Strong knowledge of medical terminology and clinical documentation standards, with attention to detail.

Nice to have

• MAC or RAC appeals review experience.
• CPC or similar coding certification.
• Experience as a Medicare medical review nurse for a MAC, RAC, QIO, or SMRC-type contractor.
• Insurance industry experience.

Culture & Benefits

• Fully remote work in a climate-controlled environment.
• Purpose-driven culture focused on straightforward communication and clinical expertise.
• Annual training and ongoing HIPAA/PHI compliance requirements.
• Reasonable accommodations are available for individuals with disabilities.