Medical Reviewer

Simsy Ventures

. Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals .

Posted 9/30/2026full-timeRemote • United StatesMid-LevelSenior💰 $62,000 - $65,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in medical review processes, including assessment of payment determinations and medical necessity, while effectively communicating with internal and external teams. Holds an active RN license and possesses strong analytical and decision-making skills to support quality control and compliance.

Highest-signal resume keywords

Active RN LicenseClinical ExperienceMedical Review Criteria InterpretationMicrosoft Office ProficiencyCustomer Service Skills

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Clinical AssessmentPayment Determination EvaluationMedical Necessity EvaluationUtilization ReviewQuality Assurance

Soft Skills

Analytical SkillsOrganizational SkillsDecision-Making SkillsCommunication SkillsCritical Thinking Skills

Tools & Technologies

Microsoft OfficeWord Processing Software

Certifications & Qualifications

Active RN LicenseAssociate Degree in Nursing

Industry Keywords

Medicare GuidelinesManaged CareInpatient SettingsOutpatient SettingsFraud and Abuse Referrals

About the role

Key responsibilities & impact

Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals
Assess payment determinations using clinical information and established guidelines
Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement
Provide clear, well-documented rationales for service approvals or denials
Educate internal and external teams on medical review processes, coverage determinations, and coding requirements
Support quality control activities to meet corporate and team objectives
Assist with special projects and additional responsibilities as assigned

Requirements

What you’ll need

Active, unrestricted RN license in the U.S. and in the state of hire OR Active compact multistate RN license (as defined by the Nurse Licensure Compact)
Associate Degree in Nursing OR Graduate of an accredited School of Nursing
Minimum two years of clinical experience plus at least two years in one of the following: Inpatient/Outpatient settings; Utilization/Medical Review; Intensive care (ICU/ER); Quality Assurance
Familiarity with Medicare Part A/B/HHH guidelines
Strong clinical background in managed care and/or inpatient/outpatient settings
Ability to interpret and apply medical review criteria and clinical guidelines
Proficiency in Microsoft Office and word processing software
Strong analytical, organizational, and decision-making skills
Ability to work independently while managing priorities effectively
Excellent customer service, communication, and critical thinking skills
Ability to handle confidential information with discretion
Must have lived in the United States for at least 3 out of the last 5 years to pass the required background check
Private home office with high-speed, hardwired internet
Fiber internet; 5G satellite home internet is not permitted
Must pass background check and drug testing prior to start; some positions may require fingerprinting

Benefits

Comp & perks

401(k) and company match
PTO that grows the longer you stay
Health, Vision, Dental
Company provided Life Insurance and Voluntary Life Insurance
Short Term Disability and Long Term Disability
Reasonable accommodations are available for applicants with disabilities