Clinical Medical Review Nurse
Clinical Medical Review Nurse
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Job Description
Position: Clinical Medical Review Nurse
Location: Baltimore MD #HYBRID (occasionally be required to visit provider offices)
Duration: Long term
Job Description:
- 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 FEP 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.
- 3 years acute clinical experience previous case management discharge planning or utilization review experience
- Experience required in Electronic Medical Record Retrieval
- Education: Bachelors degree in Nursing
- 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 webbased technology. Proficient
- Electronic Medical Record Retrieval Experience
- Must possess excellent verbal and written communication skills. Advanced
Licenses/Certifications:
RN or LPN Registered Nurse/Licensed Practical Nurse State Licensure And/or Compact State Licensure RNVA DC and or MD
ESSENTIAL FUNCTIONS:
35% 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 highlevel research on topics identified as actual or potential medical policies. Assesses and communicates impact of information on medical policy.
25% 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 uptodate on coding rules and standards.
25% Participates in medical policy meetings nurses forums and review sessions with Medical and Dental directors special projects and task forces committees as assigned.
15% Performs medical underwriting and risk assessment by reviewing applications of potential subscribers as well as any appropriate medical records.
Thanks & Regards
LAXMAN
KMM Technologies Inc.
CMMI Level 2 ISO 9001 ISO 20000 ISO 27000 Certified
WOSB SBA 8(A) MDOT MBE & NMSDC MBE
Tel: (240)Email:
Employment Type
Full Time
