Clinical Review Nurse - Remote

ARC Group is recruiting for CLINICAL REVIEW NURSE – REMOTE (GEORGIA RESIDENTS ONLY)

ARC Group has multiple openings for Clinical Review Nurses ! These are 100% remote, full-time, direct hire positions offering competitive salary, benefits, and excellent career growth opportunities within a dynamic and respected organization.

At ARC Group, we value diversity, equity, and inclusion. We believe that diverse perspectives drive better innovation and problem-solving. We encourage candidates from underrepresented groups to apply.

Location Requirement: Candidates must reside in Georgia and have permanent U.S. work authorization . We do not consider candidates from outside companies (no C2C or third-party arrangements).

Summary

The Clinical Review Nurse reviews healthcare claims and makes determinations regarding the validity of claims and levels of payment based on national and local policies and accepted medical standards. Using clinical expertise, the nurse assesses medical necessity, service levels, and appropriateness of care, including prior authorization, complex pre-payment, and post-payment medical review cases.

Essential Duties & Responsibilities

Clinical Review (≈90% of time):

• Review and analyze complex pre- and post-payment healthcare claims from a clinical perspective, including prior authorizations.

• Conduct reviews of claim data and medical records to determine coverage, medical necessity, utilization, and appropriateness of care per policy and accepted standards.

• Review provider practices for potential overpayment, corrective action, fraud, or abuse; make recommendations for follow-up actions.

• Process claims and complete project work in relevant systems.

Provider Education & Special Projects (≈10% of time):

• Identify providers requiring education and provide one-on-one or group instruction based on medical review findings.

• Participate in special projects as assigned, collaborating with CMS leaders and provider communities when necessary.

Required Qualifications

• Valid nursing degree

• Minimum of 2 years clinical experience

• Strong written and verbal communication skills

• Experience evaluating medical and healthcare delivery issues (e.g., Inpatient Rehabilitation Facility)

• Proficient in Microsoft Office

• Valid, unrestricted Registered Nurse (RN) license

Preferred Qualifications

• Inpatient Rehabilitation Facility experience

• Bachelor of Science in Nursing (BSN)

• Insurance industry experience

• Certified Coder