Reach me on Tel :
240) 800-0039 Email :
Position : Clinical Medical Review Nurse
Location : Baltimore, MD #HYBRID (occasionally be required to visit provider offices)
Duration : Long term
Job Description :
- 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 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 .
- 3 years acute clinical experience, previous case management, discharge planning or utilization review experience
- Experience required in Electronic Medical Record Retrieval
- Education : Bachelor's degree in Nursing
- Ability to effectively communicate and provide positive customer service to every internal and external customer, Proficient
- Strong interpersonal skills. Ability to work independently, as well as a member of a team , Advanced
- Current knowledge of clinical practices and related medical policies., Proficient
- Strong organizational skills, ability to prioritize responsibilities with attention to detail., Proficient
- Experience in using Microsoft Office (Excel, Word, Power Point, etc.) and web-based technology., Proficient
- Electronic Medical Record Retrieval Experience
- Must possess excellent verbal and written communication skills. , Advanced
Licenses / Certifications :
RN or LPN - Registered Nurse / Licensed Practical Nurse - State Licensure And / or Compact State Licensure RN-VA, DC and or MD
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 high-level research on topics identified as actual or potential medical policies.
Assesses and communicates impact of information on medical policy.
25% 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.
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.
Thanks & Regards,
LAXMAN
KMM Technologies, Inc.
CMMI Level 2 ISO 9001 ISO 20000 ISO 27000 Certified
WOSB, SBA 8(A), MDOT MBE & NMSDC MBE
Tel : (240) 800-0039 Email : [email protected]
Senior Clinical Nurse I, Emergency Department, $15K Sign-on Bonus
Serves as a clinical expert and professional resource for the unit nurses; mentors and coaches other nurses to advance their development. Joseph Medical Center, you’re coming to more than simply a beautiful 37-acre, 218-bed suburban Baltimore, Maryland campus. Advances clinical practice on the...
Clinical Medical Review Nurse
The Clinical Medical Review Nurse (RN/LPN) will report to the Clinical Support Supervisor HEDIS and work as part of the Quality Team. Position: Clinical Medical Review Nurse. Client: Medical Device Manufacturing Company. Responsibilities include conducting HEDIS overreads per NCQA guidelines, assist...
Dialysis Clinical Manager Registered Nurse - RN
About this role: As a Clinical Manager with Fresenius Medical Care, you will ensure that quality patient care is delivered while maintaining clinical operations. PHYSICIANS: Facilitates the application process for physician privileges and compliance with Fresenius Medical Care Medical Staff By-Laws....
Senior Clinical Nurse II, Wound Care, 15K Sign On Bonus, Days - University of Maryland Medical System
Leadership, Clinical and/or Technical SkillsExhibits a high level of critical thinking and clinical competency related to the patient population in the area of expertise. Participates in the growth, development, and support of wound champion nurses and fellow staff on clinical units to assure proper...
Clinical Research Nurse
Job DescriptionJob SummaryThe Office of Clinical Research is hiring a Clinical Research Nurse (CRN) to assist with carrying out clinical trials in both oncology and non-oncology research. Today's Standard of Care was Yesterday's Clinical Trial. Consider Clinical Research!"This is a full-time positio...
Senior Clinical Nurse I
Current and active specialty certification, OR o Current matriculation or completion of a degree or certificate program (Post-Baccalaureate or higher, 12 credits or greater) within the past 24 months, OR o Formal teaching (submit signed “Approval for Formal Teaching”) within the past 24 months, OR o...
Senior Clinical Nurse II, Wound Care, 15K Sign On Bonus, Days
Participates in the growth, development, and support of wound champion nurses and fellow staff on clinical units to assure proper wound care 24/7. Designs and implements comprehensive wound care direction to clinical staff and specified patient populations using evidence-based practice. Guides staff...
Clinical Nurse II, Telemetry, Staffing Center, Long Term Assignments, Variable Shifts, Shore Medical Center
The Clinical Nurse II (Per Diem and LTA), is responsible for providing direct and indirect patient and family care in inpatient and approved surgical and ambulatory care areas. The nurse is expected to competently perform the patient care responsibilities of the registered nurse within the assigned ...
Senior Clinical Nurse I
Current and active specialty certification, OR o Current matriculation or completion of a degree or certificate program (Post-Baccalaureate or higher, 12 credits or greater) within past 24 months, OR o Formal teaching (submit signed "Approval for Formal Teaching") within past 24 months, OR o Member ...
Clinical Nurse Coordinator, Ambulatory Services, Coordinated Care Clinic
In addition, the nurse coordinator collaborates with the multi-disciplinary team and utilizes clinical outcomes data to support innovative and cost-effective changes to clinical practice. Serves as an effective Primary Coordinating Nurse; collaborates and coordinates with physicians and all discipli...