Job Description

Clinical Medical Review Nurse

Seeking a Medical Review Nurse for a long term contract position with our customer, a major Healthcare Insurance organization in the Maryland area. The 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. Specifically, we are seeking candidates that are RN or LPN certified, and medical chart review experience.

This position is a hybrid opportunity, reporting to our clients office in Canton MD 2-3x per week.

Required Skills

- RN or LPN certified is a requirement. Licensed in Maryland. (Licensure Compact-(NLC) acceptable)
- Experience: 5+ years acute clinical experience, previous case management, discharge planning or utilization review experience.
- Must have strong Medical Abstraction/Data Analysis abilities
- Bachelor's or Associate-s degree in Nursing is highly preferred
- Big Plus: HEDIS medical chart review experience. Overreading also a big plus
- CareSeed knowledge considered a BIG PLUS
- Expertise within any EMR is required (Big Plus would be Epic, eClinical or Cerner)
- Ability to effectively communicate and provide positive customer service to every internal and external customer
- Current knowledge of clinical practices and related medical policies.

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Job Tags

Contract work, Long term contract, Work at office,

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