Job Summary
We are seeking a Bilingual Registered Nurse - Remote for a temp-to-hire opportunity supporting clinical claims review within the healthcare services industry. This role is ideal for a licensed nurse or certified coding professional who is detail-oriented, comfortable working with medical records, and interested in using clinical knowledge in a remote, analytical role.
In this position, you will review professional or facility claims against medical records to determine whether services are supported, help ensure compliance with reimbursement and contract guidelines, and provide clear clinical reasoning when needed. This opportunity offers structured expectations, collaboration with internal teams, and the chance to build experience in clinical review, claims resolution, and healthcare compliance.
Key Responsibilities
- Perform clinical reviews of professional or facility claims compared with medical records to determine whether claims are supported or unsupported.
- Maintain departmental standards for productivity, accuracy, documentation, and clinical review quality.
- Provide clear and concise clinical logic to providers and internal teams when claim determinations require explanation.
- Investigate, recover, and resolve claims for health plans, commercial customers, and government entities.
- Ensure adherence to state and federal compliance policies, reimbursement policies, and contract requirements.
- Participate in internal customer meetings, provide feedback, and support continuous improvement across team processes.
Compensation and Benefits
- Pay rate: $21 per hour.
- Job type: Temp-to-hire.
- Work arrangement: Remote.
- Location: San Juan, PR.
- Benefits: Not specified.
Required Qualifications and Skills
- Conduct clinical case reviews using medical records, claims data, and applicable documentation standards.
- Investigate claims issues and support recovery, resolution, and compliance processes.
- Document findings clearly while maintaining data integrity, data security, and process accuracy.
- Collaborate with internal teams to improve communication, workflow, and department relationships.
- Active Puerto Rico Registered Nurse license or applicable coding certification.
- Accepted certifications may include CPC, CPC-A, CIC, COC, CPMA, or CCS.
- Demonstrated proficiency with computers and the ability to work accurately in healthcare systems and documentation tools.
- Ability to interpret medical records, claims information, reimbursement requirements, and compliance guidelines.
- Strong attention to detail, analytical thinking, and problem-solving skills.
- Ability to communicate clinical findings clearly and professionally in a remote work environment.
- Entry-level candidates with less than 1 year of experience may be considered if licensing or certification requirements are met.
Preferred Qualifications
- Experience reviewing healthcare claims, medical records, or clinical documentation.
- Familiarity with health plan operations, claims recovery, reimbursement policies, or government healthcare programs.
- Prior remote work experience in a healthcare, clinical review, coding, or claims environment.
Equal Opportunity Employer / Disabled / Protected Veterans
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For temporary assignments lasting 13 weeks or longer, AppleOne is pleased to offer major medical, dental, vision, 401k and any statutory sick pay where required.
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