RN Claims Reviewer

About the Role

Capitol Bridge Puerto Rico is seeking an experienced Registered Nurse to conduct impartial healthcare claim dispute reviews supporting the Florida CDR and multi-state IRO programs. The RN Claims Reviewer evaluates clinical and claim documentation, identifies information needed to resolve disputes, collaborates with coding and other credentialed clinical professionals, and develops clear, evidence-supported review findings and determination documentation. Coding and claims experience are strongly preferred.

Payrate: $26.44/hr

Key Responsibilities

• Conduct comprehensive review of documentation submitted by initiating and responding parties in healthcare claim disputes.
• Identify missing clinical or claim documentation and follow established procedures to obtain information needed for review.
• Evaluate medical necessity, appropriateness of care, and clinical support for services or procedures at issue within the reviewer’s scope.
• Review relevant claim information, CPT/HCPCS codes, EOBs, medical records, and supporting documentation; collaborate with a Coding Specialist when specialized coding analysis is required.
• Determine when review by a physician, coder, attorney, or other credentialed specialist is necessary and prepare the case for specialty review.
• Apply applicable governmental, professional, clinical, and project-specific guidelines to support defensible findings.
• Collaborate with attorneys and program leadership on complex or escalated disputes while maintaining appropriate clinical independence.
• Draft clear, professional determination narratives and supporting documentation.
• Communicate with health plans, providers, enrollees, and internal team members as needed under established procedures.
• Complete assigned reviews within required turnaround times and meet Quality Assurance/Quality Control standards.
• Maintain current knowledge of project procedures and implement applicable regulatory, policy, and client-directed changes.

Required Qualifications

• Active, unrestricted Registered Nurse license valid for the work performed in Puerto Rico.
• At least five years of full-time equivalent experience providing direct patient care.
• Strong clinical judgment and ability to evaluate complex medical documentation objectively.
• Strong written English communication skills with the ability to produce concise, defensible review narratives.
• Ability to manage sensitive and confidential information and work independently within defined deadlines.

Preferred Qualifications

• Healthcare claims review, appeals, utilization review, payment dispute, or independent medical review experience.
• Experience or formal training in medical coding, including CPT, HCPCS, ICD-10-CM, modifiers, EOBs, and claim documentation.
• Coding credential such as CPC, CCS, CCA, or comparable certification is a plus but not required.
• Experience collaborating with physicians, coding professionals, attorneys, health plans, and healthcare providers.
• Bilingual English/Spanish communication skills.

What Success Looks Like

Reviews are timely, clinically sound, well documented, and supported by the record and applicable guidance. The reviewer knows when a question is clinical, when coding expertise is needed, and when an issue should be escalated for legal or specialty review.

Required Screenings

Employment is contingent upon successful completion of applicable background screening requirements.

Reasonable Accommodation

Reasonable accommodation may be made to enable qualified individuals with disabilities to perform the essential functions of this position. Additional duties may be assigned based on program needs.

Equal Employment Opportunity

Capitol Bridge Puerto Rico is an Equal Opportunity Employer. Employment decisions are based on business needs, job requirements, and individual qualifications, without regard to any status protected by applicable law.