Medical Review Nurse

Medical ReviewerMedical ReviewerFull TimeRemoteMid LevelTeam 10,001+Since 1931H1B SponsorCompany SiteLinkedIn

Location

United States

Posted

1 day ago

Salary

$62.1K - $104.0K / year

Seniority

Mid Level

No structured requirement data.

Job Description

Medical Review Nurse

Allstate

Role Description Are you a clinically experienced Registered Nurse looking to apply your expertise beyond direct patient care? As a Medical Review Nurse you will play a critical role in strengthening risk management and improving decision-making across our health and accident products. You’ll use your clinical knowledge to evaluate medical records, guide coverage determinations, and support fair, evidence-based appeal outcomes—directly impacting both business outcomes and member experience. This is an opportunity to bring your clinical judgment, analytical thinking, and passion for quality care into a dynamic, fast-paced environment where your insights drive meaningful results. What You’ll Do - Serve as a trusted clinical expert supporting accident and health lines of business - Review medical records and claims to determine coverage and benefit eligibility - Evaluate medical necessity and appropriateness of care based on evidence-based guidelines - Draft clear, defensible written rationales for coverage and appeal determinations - Analyze medical and claims data to identify trends, risks, and improvement opportunities - Assess medical information to determine current and potential risk exposure for coverage decisions - Interpret and apply policy contract language to ensure consistent, accurate determinations - Synthesize complex data from multiple sources to inform business decisions - Maintain strong productivity and quality in a high-volume, fast-paced environment - Collaborate cross-functionally while demonstrating strong independence and accountability Qualifications - Active Registered Nurse (RN) license - Proven ability to analyze and interpret complex medical information and documentation - Strong clinical judgment and decision-making skills - Excellent written and verbal communication skills Requirements - 5+ years of clinical nursing experience - Experience in health insurance, utilization review, medical claims, or appeals - Familiarity with medical coding systems (CPT, ICD-10, HCPCS) and claims documentation - Experience interpreting insurance policy language and applying it in decision-making - Exposure to data analysis and identifying trends within medical or claims data Key Skills & Strengths - Analytical mindset with strong attention to detail - Ability to translate clinical complexity into clear, actionable insights - Strong problem-solving and critical thinking capabilities - Effective time management and ability to prioritize competing demands - Comfortable working both independently and collaboratively Tools & Expertise - Proficiency in Microsoft Office (Excel, Word, Outlook) - Experience working with medical records, physician notes, and evidence-based clinical studies - Ability to interpret Explanation of Benefits (EOBs) and submitted claims Benefits - Compensation offered for this role is $62,100.00 - $103,950.00 annually and is based on experience and qualifications. - Comprehensive technology setup, including a laptop, monitors, headset, keyboard, and mouse. - Monthly connectivity reimbursement for employees eligible to work from home.

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