Sr. Nurse Reviewer (Medicare)

Location: Fully remote, United States (VA)

Salary: $88,000–$115,000 per year

Company

hirify.global develops data-centric, healthcare-relevant, value-based solutions that combine quality data, technology, and clinical expertise to improve care efficiency and health outcomes.

What you will do

• Conduct high-complexity and escalated clinical reviews of Medicare Part A/B and DMEPOS claims.
• Make medical determinations using Medicare policies, clinical guidelines, coding rules, and accepted standards of care.
• Mentor Nurse Reviewers, Certified Coders, and other clinical review staff on complex claims.
• Lead or support inter-rater reliability and peer-review quality assurance activities.
• Monitor team accuracy and quality trends, recommend corrective actions, and implement process improvements.
• Support Program Integrity vulnerability identification, root-cause analysis, training materials, and HIPAA/PHI compliance.

Requirements

• Bachelor's degree in nursing or a related healthcare field.
• Active, unrestricted RN license; a compact multistate RN license is acceptable.
• 5+ years of clinical experience, including 3+ years of Medicare utilization review, medical review, or claims review experience.
• Experience providing guidance, mentorship, or lead-level direction to clinical reviewers or coding staff.
• Extensive knowledge of Medicare coverage, coding, payment rules, and NCD/LCD application.
• Strong analytical, written, and verbal communication skills, with discretion when handling confidential information.

Nice to have

• Senior or lead reviewer experience on a MAC, RAC, QIO, or SMRC-type contract.
• Experience with inter-rater reliability or peer-review quality assurance programs.
• CPC or similar coding certification.
• Experience preparing case files for Administrative Law Judge hearings.

Culture & Benefits

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