Clinical medical review nurse

Job Overview

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 candidate 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.

Essential Functions

• 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.

Qualifications

To perform this job successfully, the candidate must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

• 3+ years of acute clinical experience.
• Previous case management, discharge planning or utilization review experience.
• RN - Registered Nurse - State Licensure and/or Compact State Licensure (VA, DC and or MD required upon hire).
• LPN - Licensed Practical Nurse - State Licensure and/or Compact State Licensure (VA, DC and or MD required upon hire).

Preferred Qualifications

• Bachelor's degree in Nursing.

Knowledge, Skills and Abilities (KSAs)

• Ability to effectively communicate and provide positive customer service to every internal and external customer.
• Strong interpersonal skills and the ability to work independently, as well as a member of a team.
• Current knowledge of clinical practices and related medical policies.
• Strong organizational skills and the ability to prioritize responsibilities with attention to detail.
• Experience in using Microsoft Office (Excel, Word, PowerPoint, etc.) and web-based technology.
• Strong verbal and written communication skills.
• Remote EMR access experience is essential.
• Ambulatory practice experience.
• Due to nature of job The candidate must have Ability to travel to provider locations to retrieve medical records.