Clinical Medical Review Nurse (Remote)

PURPOSE

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 post claim medical review for Commercial lines of business. 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.
• Affirms and communicates the 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.
• Participates in medical policy meetings, nurses' forums, and review sessions with Medical and Dental directors, special projects and task forces committees as assigned.

Qualifications

• Education Level: Bachelor's Degree in Nursing OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
• Licenses/Certifications: Upon Hire Required RN - Registered Nurse - State Licensure And/or Compact State Licensure RN-VA, DC and or MD.
• Experience: 3 years acute clinical experience, previous case management, discharge planning or utilization review experience.

Preferred Qualifications

• Bachelor's degree in Nursing.
• Previous experience making clinical decisions related to post claim submission and/or appeals and grievances within a health payer organization.