Medical Reviewer Remote Jobs in Kentucky (US)

This page tracks remote medical reviewer openings that are location-eligible for Kentucky.

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976

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$20 - $91,700

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976 Jobs

442 Companies

Coding Quality Reviewer

Rightworks, LLC

Rightworks, LLC provides cloud services built specifically for accounting firms and professionals. As an employer, the company strives to build a welcoming atmo

Medical Reviewer16 hours ago

Full Time Remote Senior

Company Site

Title: Coding Quality Reviewer Location: Nashville, Tennessee, United States Job Description: As a Coding Quality Review (CQR) Specialist, you will operate in a work from home environment supporting all CQR team related systems and tools. You will perform internal quality assessment reviews on Health Information Management Service Center(HSC) coders to ensure compliance with national coding guidelines, the HSC coding policies and the Company coding policies for complete, accurate and consistent coding which result in appropriate reimbursement and data integrity. Job Responsibilities - Lead, coordinate and perform all functions of quality reviews (routine, pre-bill, policy driven and incentive plan driven)for inpatient and outpatient coding across multiple HSCs - Assist in ensuring HSC coding staff adherence with coding guidelines and policy - Demonstrate and apply expert level knowledge of medical coding practices and concepts - Participate on special reviews or projects - Maintain or exceed 95% productivity standards - Maintain or exceed 95% accuracy - Meet all educational requirements as stated in current Company policy - Review all official data quality standards, coding guidelines, Company policies and procedures, and clinical/medical resources to assure coding knowledge and skills remain current Qualifications - Undergraduate degree in HIM/HIT preferred (Associate's or Bachelor's) - RHIA, RHIT and/or mandatory - IP Coding Auditor for MS-DRG - Must have experience in all body systems – cannot be specialized in one area i.e., Orthopedic etc. - Must have 3 years of hands on coding MS-DRG auditing in a hospital setting. - Cannot be a recent graduate needs experience ideally 10+ years of coding and 3 years of auditing in MS-DRG Inpatient medical records. We cannot employee candidates who reside in California, Alaska, New York or Colorado for any of our work from home positions Will be expected to complete a coding test (20 Multiple Choice/True/False 5-7 Open ended Behavioral questions- 90 minutes long Additional information - FTE’s-4

View details: Coding Quality Reviewer

United States

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Telephonic Registered Nurse Clinical Reviewer

The Cigna Group

Medical Reviewer22 hours ago

Full Time Remote Mid LevelTeam 10,001+Since 1982H1B No Sponsor

Company Site LinkedIn

Role Description The Clinical Reviewer will be responsible for: - All clinical certification activities, which include but are not limited to evaluating telephone, fax or WEB requests for authorization of clinical services from physician offices and/or imaging centers, comparing requests against established clinical protocols and authorizing services or referring requests for expert clinical review as appropriate. - Know and understand complex case specialties and case reviews. - Review clinical information submitted by providers to appropriate criteria and standards and makes decision to issue a review determination or to refer to physician review if criteria are not met. - Maintain current departmental standards related to productivity. - Train in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures. - Prepare program correspondence as needed. - Serve as a resource for members calling for assistance. - Make outbound calls as required. - Refer provider and member complaints, and appeals to appropriate departments. - Maintain patient confidentiality in accordance with EviCore standards established in compliance with HIPAA and State regulations. - Provide outstanding customer service ensuring callers receive the highest possible service. - Run and analyze reports to ensure all tasks are completed in a timely fashion and meet regulatory requirements. - Assist team members in departmental chats, by phone and in person. - Act as training assistant when assigned. - Assist team members with questions, participates in team meetings. Can be assigned to projects to support the department as needed. - Perform related duties as required. Essential Functions: - Must be able to sit through shift, demonstrate advanced proficiency in MS Office applications. - Excellent communication skills both verbal and written. - Excellent problem solving and customer service skills are required. - Must be self-directed and highly motivated with an ability to multi-task. - Excellent computer skills. - Must be able to hear and speak on the phone for an entire shift. Qualifications - Associates Degree in Nursing required. - Current, unrestricted license as an RN in state of primary residence. - Must have at least 1 year of acute care, managed care, ER, ICU experience or 2 years of clinical utilization management experience. - If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload. Requirements - For this position, we anticipate offering an hourly rate of 31 - 52 USD / hourly, depending on relevant factors, including experience and geographic location. - This role is also anticipated to be eligible to participate in an annual bonus plan. Benefits - Comprehensive range of benefits, with a focus on supporting your whole health. - Health-related benefits including medical, vision, dental, and well-being and behavioral health programs starting on day one of employment. - 401(k), company paid life insurance, tuition reimbursement. - A minimum of 18 days of paid time off per year, paid holidays, and leaves of absence.

View details: Telephonic Registered Nurse Clinical Reviewer

United States

$31 - $52 / hour

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Telephonic Registered Nurse Clinical Reviewer

The Cigna Group

Medical Reviewer22 hours ago

Other Remote Mid LevelTeam 10,001+Since 1982H1B No Sponsor

Company Site LinkedIn

Role Description The Clinical Reviewer will be responsible for: - All clinical certification activities, which include but are not limited to evaluating telephone, fax or WEB requests for authorization of clinical services from physician offices and/or imaging centers. - Comparing requests against established clinical protocols and authorizing services or referring requests for expert clinical review as appropriate. - Understanding complex case specialties and case reviews. - Reviewing clinical information submitted by providers to appropriate criteria and standards and making decisions to issue a review determination or to refer to physician review if criteria are not met. - Maintaining current departmental standards related to productivity. - Training in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures. - Preparing program correspondence as needed. - Serving as a resource for members calling for assistance. - Making outbound calls as required. - Referring provider and member complaints, and appeals to appropriate departments. - Maintaining patient confidentiality in accordance with EviCore standards established in compliance with HIPAA and State regulations. - Providing outstanding customer service ensuring callers receive the highest possible service. - Running and analyzing reports to ensure all tasks are completed in a timely fashion and meet regulatory requirements. - Assisting team members in departmental chats, by phone and in person. - Acting as training assistant when assigned. - Assisting team members with questions and participating in team meetings. - Performing related duties as required. Essential Functions: - Must be able to sit through shift, demonstrate advanced proficiency in MS Office applications. - Excellent communication skills both verbal and written. - Excellent problem solving and customer service skills are required. - Must be self-directed and highly motivated with an ability to multi-task. - Excellent computer skills. - Must be able to hear and speak on the phone for an entire shift. Qualifications - Associates Degree in Nursing required. - Current, unrestricted license as an RN in state of primary residence. - Must have at least 1 year of acute care, managed care, ER, ICU experience or 2 years of clinical utilization management experience. - If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload. Requirements - For this position, we anticipate offering an hourly rate of 31 - 52 USD / hourly, depending on relevant factors, including experience and geographic location. - This role is also anticipated to be eligible to participate in an annual bonus plan. Benefits - Comprehensive range of benefits, with a focus on supporting your whole health. - Health-related benefits including medical, vision, dental, and well-being and behavioral health programs starting on day one of employment. - 401(k), company paid life insurance, tuition reimbursement. - A minimum of 18 days of paid time off per year, paid holidays, and leaves of absence.

View details: Telephonic Registered Nurse Clinical Reviewer

United States

$31 - $52 / hour

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Medical Records Clerk/Appeals Specialist

Pro Med Healthcare Services

Medical Reviewer4 days ago

Contract Remote Mid Level

Role Description The Medical Records Clerk Appeals Specialist oversees the managing of patient health files in a facility. Their duties include: - Filing records - Assisting in audits - Collecting information - Supplying the nursing department with appropriate documents and forms This role serves as the primary point of contact for all record requests and ensures the accurate, timely, and confidential handling of clinical documentation for clients, families, referents, legal entities, payers, and regulatory agencies. Additionally, the position supports the Utilization Review team by preparing and tracking written insurance appeals. Qualifications - Strong knowledge of HIPAA and confidentiality regulations - Familiarity with AHCA, DCF, and CARF standards - Ability to manage high volumes of requests while maintaining accuracy and timeliness - Excellent attention to detail and organizational skills - Proficiency in EHR platforms (e.g., BestNotes) and Microsoft Office Suite - Strong written and verbal communication skills - Professional discretion and ability to maintain confidentiality in all matters - Understands and maintains professional boundaries - Demonstrates an understanding of rules/limits of patient confidentiality and maintains appropriate levels of client confidentiality/privacy - Demonstrates consideration of and respect for values and cultural beliefs Requirements - High School Diploma or GED required - Associate’s or bachelor’s degree in health information management, Healthcare Administration, or related field preferred - Minimum of 2 years in medical records, health information management within a behavioral health or healthcare setting - Experience with payer appeals and electronic health record systems preferred - Valid Florida Driver’s License - Current CPR and First Aid Certification, or willingness to complete within the first 30 days of employment - Clearance of TB test Benefits - Pay rate: $20.00 to $22.00 an hour based on experience - Remote work opportunity - Monday through Friday hours: 8:30 AM to 5:00 PM

View details: Medical Records Clerk/Appeals Specialist

United States

$20 - $22 / hour

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Senior Medical Reviewer

Palmetto GBA

Providing healthcare administration services and technology solutions for government and corporate entities.

Medical Reviewer4 days ago

Full Time Remote SeniorTeam 1,001-5,000Since 1965H1B Sponsor

Company Site LinkedIn

Role Description Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to unit supervisor/manager by giving direction/guidance/training to staff. Ensures appropriate levels of healthcare services are provided. This position is part of the End-Stage Renal Disease QIP Contract. Logistics: - Palmetto GBA - one of BlueCross BlueShield's South Carolina subsidiary companies. Functions as a team leader/senior-level Medical Reviewer. Provides leadership/guidance/direction/training to staff. Maintains a working knowledge of unit functions and the ability to interpret to new hires, department interworking, and workflow. Acts as a resource for staff/external entities troubleshooting as well as resolving issues. Keeps manager informed of any problems/issues that need resolving. - Assists management with monitoring workflow and workloads (including reassignment of work to meet timelines, redirecting work intake source to balance workloads), reporting, and addressing aging issues. - Participates in departmental quality reviews. - Follows a process to ensure quality plan is adhered to and communicated to all parties. - Gives/receives feedback regarding medical review decision making and technical claims processing issues. - Ensures that quality work instructions/forms/documents are developed/revised as needed. - Provides quality service and communicates effectively with external/internal customers in response to inquiries. - Obtains information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems. - Participates in compliance initiatives and other directed activities. - Participates/oversees special projects as requested by management. Qualifications - Associate Degree - Nursing OR Graduate of Accredited School of Nursing. Requirements - Four years of clinical experience, OR - Two years of clinical and two years of medical review/utilization review, OR - Combination of health plan, clinical, and business experience totaling four years. Preferred Requirements - ESRD/renal dialysis experience. - Five or more years’ clinical, quality management, or leadership experience as a registered nurse in a Dialysis setting. - Three or more years’ education/training/consulting experience related to Dialysis services (may be concurrent). - Three or more years’ experience in quality management coordination related to Dialysis services (may be concurrent). Required Skills and Abilities - Working knowledge of managed care and various forms of healthcare delivery systems. - Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience. - Knowledge of specific criteria/protocol sets and the use of the same. - Working knowledge of word processing and spreadsheet software. - Ability to work independently, prioritize effectively, and make sound decisions. - Good judgment skills. - Demonstrated customer service, organizational, and presentation skills. - Demonstrated proficiency in spelling, punctuation, and grammar skills. - Demonstrated oral and written communication skills. - Ability to persuade, negotiate, or influence others. - Analytical or critical thinking skills. - Ability to handle confidential or sensitive information with discretion. - Ability to lead/direct/motivate others. Required Software and Tools - Microsoft Office. Required License and Certificate - Active, unrestricted RN licensure from the United States and in the state of hire, OR - Active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).

View details: Senior Medical Reviewer

United States

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Radiology Physician

Adelphi Staffing

Medical Reviewer4 days ago

Contract Remote Mid LevelTeam 11-50

Role Description Provide remote diagnostic radiology interpretations for the Emergency Department during overnight hours (11:00 PM – 7:00 AM EST). - Interpret and report on an average of 80–130 mixed cases per shift using Sectra PACS and Powerscribe dictation. - Supervise and teach 2–3 radiology residents, ensuring clinical guidance and educational feedback. - Ensure accurate, timely reporting in Cerner EMR, adhering to facility protocols. - Submit required case logs, NPDB report (within past 30 days), and maintain clean malpractice history. Qualifications - Board Certified - Licensed in MI - DEA waiver required (DEA not required) - BLS certification Requirements - Average Daily Volume: 80-130 cases per 8-hour shift - Rounding: Unassigned Patients - EMR System: Cerner - Hospital Privileges Required: No - Temporary Privileges Available: No Benefits - Travel, Lodging, and Malpractice Insurance: Covered by Agency

View details: Radiology Physician

United States

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Medical Review Nurse

Nuna

Nuna is committed to making high-quality healthcare affordable for everyone by leveraging data, modern technology, and compassion. The company has established its brand in the B2B space by shifting the US healthcare system towards an incentive model that rewards healthcare providers for positive outcomes.

Medical Reviewer5 days ago

Contract Remote Mid Level

Role Description Nuna is expanding how it provides care to its users. We are looking for one or more part-time, contract nurses to help us ensure we’re providing the right care to the right patients. Our understanding of our needs, and those of our patients, will evolve (and our nurses will help us develop that understanding), so the scope and the number of hours may optionally expand in the future. This is a contract role, starting with a 6-month term with the option to renew; this role will not offer benefits. We expect around 5 hours per week at the start. If you have more time and we have more work, we may increase your hours. Within certain timeframes, work can be done at your convenience. We may occasionally invite you to meetings with our team. What you’ll do - Chart Review: review patient records to ensure that patients are a good fit for the Nuna app. This will involve: - Comparing diagnoses, prescription activity, test results, and medical records from a variety of sources - Reconciling discrepancies - Support the Nuna app’s medication management features (non-prescribing) - Review medication lists for completeness, appropriateness, and potential issues (e.g. adherence concerns, duplication, gaps, etc.) - Help patients communicate with their clinical teams about potential opportunities to improve medication experience - Liaise with clinical teams about patient medication experience - Support Nuna’s Medical Director in developing programs and processes to best support the care of Nuna patients - Assist in the design of future clinical tasks and responsibilities - Provide product feedback to Nuna product teams - Participate in quality improvement efforts Qualifications - Licensure in Illinois (required) - 6 months of clinical chart review experience - Comfortable learning new technology Bonus Points - Licensure in California and/or Tennessee - Experience with cardio-metabolic care - Interest in digital health and informatics - Experience with risk adjustment review of medical records

View details: Medical Review Nurse

United States

$40 - $50 / hour

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Registered Nurse-Initial Clinical Reviewer

Blue Cross Blue Shield of Arizona

Inspiring Health in Arizona for over 80 years.

Medical Reviewer5 days ago

Full Time Remote Mid LevelTeam 1,001-5,000Since 1939H1B Sponsor

Company Site LinkedIn

Role Description Responsible for identifying, researching, processing, resolving, and responding to inquiries from internal and external customers with emphasis on excellence, privacy, compliance and versatility within the health insurance industry. Qualifications - REQUIRED QUALIFICATIONS - 2 years of experience in clinical field of practice, health insurance, or other health care related field - Associate’s Degree in general field of study or Post High School Nursing Diploma or Certification (LPN only) from an approved program - Active, current, and unrestricted license to practice in the State of Arizona (or an endorsement to work in Arizona) as a behavioral health professional such as LCSW, LPC, LISAC, LMFT, or licensed psychologist (Psy.D. or Ph.D.), OR an active, current, and unrestricted license to practice nursing in either the State of Arizona or another state in the United States recognized by the Nursing Licensure Compact (NLC) as an RN, OR an active, current, and unrestricted license to practice in the State of Arizona as an LPN. - PREFERRED QUALIFICATIONS - 3 years of experience in clinical field of practice, health insurance, or other health care related field - Bachelor's Degree in Nursing or related field of study - Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse Requirements - Identify, research, process, resolve and respond to customer inquiries and correspondence via telephone, written communication and/or in person. - Answer a diverse and high volume of health insurance related customer calls or correspondence on a daily basis. - Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of benefit requests. - Maintain complete and accurate records per department policy. - Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations. - Explain to customers a variety of information concerning the organization’s services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, provider networks, etc. - Demonstrate ability to apply plan policies and procedures effectively. - Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries. - Collaborate with team to distribute workload/work tasks. - Monitor and report team tasks. - Communicate team issues and opportunities for improvement to supervisor/manager. - Support/mentor team members. - Participate in continuing education and current developments in the fields of medicine and managed care. - Maintain all standards in consideration of State, Federal, BCBSAZ and other accreditation requirements. - The position has an onsite expectation of 5 days per week and requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements. - Perform all other duties as assigned. Company Description Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions. At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. - Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week - Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week - Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month - Onsite: daily onsite requirement based on the essential functions of the job - Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week. This remote work opportunity requires residency, and work to be performed, within the State of Arizona.

View details: Registered Nurse-Initial Clinical Reviewer

United States

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Clinical Reviewer

Noridian Healthcare Solutions, LLC

Medical Reviewer6 days ago

Full Time Remote Mid LevelTeam 1,001-5,000

Role Description The Clinical Reviewer (RN) evaluates medical records applying clinical expertise to determine compliance with applicable guidelines and standards of care. This position documents decisions and rationale and communicates results with stakeholders through various means providing education and guidance. Essential Functions - Reviews, researches, and analyzes medical records and other documentation to determine compliance with regulations, guidelines, and standards of care. - Applies accurate, independent coverage and payment decisions using consistent evaluation standards. - Communicates decisions and provides associated education to stakeholders using various methods. - Determines recommendations for actions based on analysis of review results. - Prioritizes workload depending on business need and direction. - Identifies and communicates potential fraud, waste, and abuse using established work instructions. - Collaborates and communicates with peers and leaders. - Participates in team quality and calibration review processes. - Serves as a mentor to peers. - May prepare documents for, and participate in, legal hearings. Qualifications - Current, active, unrestricted RN license in state of practice - 2 years' clinical experience - 1 year Microsoft Office experience - Strong verbal and written communication skills - Strong computer experience Requirements - Bachelor's degree in Nursing (BSN, BAN, etc.) - 1 year experience evaluating medical records applying clinical expertise to determine compliance with applicable guidelines and standards of care - 1 year experience in utilization review or case management - 1 year experience educating external customers - 1 year experience leading projects, initiatives, or processes - Strong prioritization, problem solving, and organizational skills - Strong attention to detail - Knowledge of coding - Microsoft proficiency - Strong business writing experience Benefits - Health, Dental and Vision Insurance - Voluntary Insurance Plans - Health Savings and Flexible Spending Accounts - 401k and Company Match - Company-paid Life Insurance - Education Assistance Program - Paid Sick Leave - Paid Holidays - Increasing PTO Accrual Plan - Medical/Parental/Disability Leave - Workers Compensation - Retiree Benefits - Severance Package - Employee Assistance Program - Financial and Health Wellness Benefits - Casual Dress - Open Office Setting - Online Learning System

View details: Clinical Reviewer

United States

$52.1K - $78.9K / year

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Licensed Psychologist, Peer Reviewer

UnitedHealth Group

UnitedHealth Group is a healthcare and well-being company that’s dedicated to improving the health outcomes of millions around the world. We are comprised of

Medical Reviewer6 days ago

Full Time Remote Mid Level

Company Site

Role Description The role of the Psychologist Peer Review for ALERT involves applying clinical criteria and benefit plan requirements to Commercial, Medicaid, and Medicare cases, and making clinical and/or benefit determinations to continue coverage of treatment, shaping and modifying treatment as appropriate, or issuing an adverse benefit determination if applicable criteria is not met. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: - Standard outpatient treatment, including requests for extended length sessions or single case agreements - State-specific Medicaid services (e.g. Psychosocial Rehabilitation, Targeted Case Management, Home Based Habilitation, Supported Employment, etc.) - Intensive Outpatient services for both Mental Health and Substance Abuse - Participate in peer consultations, staff meetings, and trainings; entering determinations within federal, state, and local guideline requirements; and perform other duties as required by the reviewer’s manager - Conduct Non-MD clinical reviews of the following type during a typical workday: - Requests for psychological or neuropsychological testing - Review of outpatient treatment plans for services that are sent for Peer Review that do not appear to meet clinical criteria and/or when there are concerns about the quality of care - Review of ongoing outpatient care in cases where the member’s treatment episode exceeds normative standards - Requests for non-standard outpatient services (extended-length visits, an in-network accommodation, intensive outpatient program with no MD involvement) - Appeals of previously denied services or claims for outpatient non-MD services up to and including Intensive Outpatient Programming You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Qualifications - Licensed doctoral level (Ph.D. or Psy.D.) Psychologist - License must be current, allow for full independent practice, and be unrestricted (you may be asked to obtain additional state licenses to meet growing business needs) - 3+ years of post-licensure experience - Experience working with insurance agencies - Computer skills, including facility with Windows OS, Outlook, Word, and Excel - Proven ability to type proficiently while speaking on the phone Requirements - Experience working in a managed care setting - Experience performing Peer Reviews - Experience with commercial, Medicaid and Medicare lines of business - Experience with CPT and HCPC codes - Clinical experience in higher levels of care (Intensive Outpatient) - Clinical experience with children and adolescents - Clinical experience with Substance Abuse diagnoses - Clinical experience with Evidence-Based Treatment - Advanced computer skills using Excel and Access Databases - Proven solid organizational and time management skills, with the ability to prioritize multiple demands within strict turn-around-time requirements - Proven solid written and verbal communication and negotiation skills - Proven ability to work well independently and collaborate with others on a clinical team - Proven ability to enjoy a fast paced, changing environment - Candidates located in Mountain or Pacific Time Zones Benefits - Comprehensive benefits package - Incentive and recognition programs - Equity stock purchase - 401k contribution (all benefits are subject to eligibility requirements) Application Deadline This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

View details: Licensed Psychologist, Peer Reviewer

United States

$91.7K - $163.7K / year

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