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Clinical Medical Review Nurse (Remote) DC VA MD
22441 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. 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. We are looking for an experienced professional to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities. The ideal candidate will have previous experience making clinical decisions related to post claim submission and/or appeals and grievances within a health payer organization. ESSENTIAL FUNCTIONS:
- Receives, research, 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.
- RN - Registered Nurse - State Licensure And/or Compact State Licensure RN-VA, DC and or MD.
- Bachelor's 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, Power Point, etc.) and web-based technology.
- Must possess excellent verbal and written communication skills.
- 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.
