HEDIS Nurse
HEDIS Nurse
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Job Description
Job Title: HEDIS Nurse/Clinical Medical Review Nurse
Client: Health Insurance Company
Duration: 12 months
Location: Baltimore MD 21224
Purpose:
The Clinical Medical Review Nurse handles daytoday 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 postclaim 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.
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 the impact of information on medical policy.
- 25% Provides pricing of procedure codes that 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.
- To perform this job successfully an individual must be able to perform each essential duty satisfactorily.
- The requirements listed below are representative of the knowledge skill and/or ability required.
- Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- 3 years of acute clinical experience previous case management discharge planning or utilization review experience.
- Bachelors degree in Nursing.
- Ability to effectively communicate and provide positive customer service to every internal and external customer.
- Strong interpersonal skills. Ability to work independently as well as a member of a team.
- Current knowledge of clinical practices and related medical policies.
- Strong organizational skills ability to prioritize responsibilities with attention to detail.
- Experience in using Microsoft Office (Excel Word PowerPoint etc.) and webbased technology.
- Electronic Medical Record Retrieval Experience.
- Must possess excellent verbal and written communication skills.
- The incumbent is required to immediately disclose any debarment exclusion or other event that makes them ineligible to perform work directly or indirectly on Federal health care programs.
- Must be able to effectively work in a fastpaced environment with frequently changing priorities deadlines and workloads that can be variable for long periods of time.
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers within set expectations for service excellence.
- Must be able to effectively communicate and provide positive customer service to every internal and external customer including customers who may be demanding or otherwise challenging.
- RN or LPN Registered Nurse/Licensed Practical Nurse State Licensure and/or Compact State Licensure RNVA DC and or MD.
Employment Type
Full Time
