Clinical Medical Review Nurse

Cynet Systems • Baltimore, MD

4d • Onsite

About The Position

The Clinical Medical Review Nurse will be responsible for reviewing, researching, and analyzing professional and institutional claims using clinical judgment and medical policies for accurate adjudication. This role involves high-level research on medical topics, assessing their impact on medical policy development, and providing pricing for procedure codes. The nurse will interpret medical and procedural information in alignment with coding standards and regulatory requirements, and participate in various medical leadership meetings and forums. Additionally, the position contributes to special projects and performs medical underwriting and risk assessment by reviewing applications and medical records of potential members.

Requirements

• Minimum 3 years of acute clinical experience.
• Experience in case management, discharge planning, or utilization review.
• Strong understanding of clinical practices and medical policy application.
• Proficiency in Microsoft Office (Excel, Word, PowerPoint) and web-based systems.
• Experience working with Electronic Medical Records (EMR) systems.
• Excellent verbal and written communication skills.

Nice To Haves

• Bachelor's degree in Nursing.
• Clinical claims review and adjudication.
• Medical coding knowledge (CPT, HCPCS).
• Medical policy analysis and research.
• Risk assessment and underwriting support.
• Strong analytical and critical thinking abilities.
• Attention to detail and organizational skills.
• Ability to work independently and collaboratively.
• Customer service and stakeholder communication.

Responsibilities

• Review, research, and analyze professional and institutional claims using clinical judgment and medical policies for accurate adjudication.
• Conduct high-level research on medical topics and assess impact on medical policy development.
• Provide pricing for procedure codes requiring individual consideration or classified as "not otherwise specified" using CPT and HCPCS guidelines.
• Interpret medical and procedural information in alignment with coding standards and regulatory requirements.
• Participate in medical policy meetings, nursing forums, and review sessions with medical and dental leadership.
• Contribute to special projects, task forces, and cross-functional initiatives.
• Perform medical underwriting and risk assessment by reviewing applications and medical records of potential members.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level