Health Services - Nurse, Clinical Medical Review

TalTeam • Baltimore, MD

2d • Onsite

About The Position

The Clinical Medical Review Nurse handles day to day review of professional and institutional claims and provider appeals that require medical review to determine if the claim is eligible for benefits and to support claims processing and/or adjudication. The incumbent will handle pre and post claim medical review for Commercial and Medicare Advantage Plans. This position assists in determining acceptable medical risk to the organization by analyzing medical information of applicants for enrollment in specific policies. This role will also understand the merits of legal or accreditation actions.

Requirements

• 3 years acute clinical experience, previous case management, discharge planning or utilization review experience
• Ability to effectively communicate and provide positive customer service to every internal and external customer, Proficient
• Strong interpersonal skills. Ability to work independently, as well as a member of a team , Advanced
• Current knowledge of clinical practices and related medical policies., Proficient
• Strong organizational skills, ability to prioritize responsibilities with attention to detail., Proficient
• Experience in using Microsoft Office (Excel, Word, Power Point, etc.) and web-based technology., Proficient
• Must possess excellent verbal and written communication skills. , Advanced
• RN - Registered Nurse - State Licensure And/or Compact State Licensure RN-VA, DC and or MD Upon Hire Req
• Ambulatory Experience

Nice To Haves

• Bachelor's degree in Nursing

Responsibilities

• Receives, researches, reviews and analyzes professional and institutional claims using critical thinking, nursing clinical judgment and corporate/medical policies for claims processing and/or adjudication, Performs high-level research on topics identified as actual or potential medical policies. Assesses and communicates impact of information on medical policy.
• Provides pricing of procedure codes which require individual consideration or are listed as "not otherwise classified” in CPT manual. Interprets the descriptive or medical information utilizing the CPT and HCPCS manuals. Keeps up-to-date on coding rules and standards.
• Participates in medical policy meetings, nurses' forums, and review sessions with Medical and Dental directors, special projects and task forces committees as assigned.
• Performs medical underwriting and risk assessment by reviewing applications of potential subscribers, as well as any appropriate medical records.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 101-250 employees