CLINICAL MEDICAL REVIEW NURSE
3 weeks ago
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 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:
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.
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable
accommodations may be made to enable individuals with disabilities to perform the essential functions.
Experience: 3 years acute clinical experience, previous case management, discharge planning or utilization review experience
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, 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
Must possess excellent verbal and written communication skills. , Advanced
The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes them ineligible to perform work directly or indirectly on Federal health care programs. Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. 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.
Licenses/Certifications
RN - Registered Nurse - State Licensure And/or Compact State Licensure RN-VA, DC and or MD Upon Hire Req
-
Clinical Review Nurse
2 weeks ago
Baltimore, Maryland, United States Johns Hopkins Medicine Full timeJohns Hopkins Care at Home (JHCH) is a leading provider of home care services, committed to delivering high-quality, patient-centered care. We are currently seeking a dedicated and experienced Clinical Review Nurse (CRN) to join our team. Collaborate with clinical staff and other team members to foster a culture of continuous improvement in documentation...
-
Clinical Review Nurse
2 weeks ago
Baltimore, United States Johns Hopkins Medicine Part timeJohns Hopkins Care at Home (JHCH) is a leading provider of home care services, committed to delivering high-quality, patient-centered care. We are currently seeking a dedicated and experienced Clinical Review Nurse (CRN) to join our team. Collaborate with clinical staff and other team members to foster a culture of continuous improvement in documentation...
-
UTILIZATION REVIEW NURSE
2 weeks ago
Baltimore, MD, United States LifeBridge Health Full timeUTILIZATION REVIEW NURSE Sign On Bonus Potential: $15,000 Baltimore, MD ...
-
UTILIZATION REVIEW NURSE
1 week ago
Baltimore, MD, United States LifeBridge Health Full timeUTILIZATION REVIEW NURSE Sign On Bonus Potential: $15,000 Baltimore, MD ...
-
UTILIZATION REVIEW NURSE
2 weeks ago
Baltimore, MD, United States LifeBridge Health Full timeUTILIZATION REVIEW NURSE - PRN Baltimore, MD ...
-
UTILIZATION REVIEW NURSE
2 weeks ago
Baltimore, MD, United States LifeBridge Health Full timeUTILIZATION REVIEW NURSE - PRN Baltimore, MD ...
-
UTILIZATION REVIEW NURSE
2 weeks ago
Baltimore, MD, United States LifeBridge Health Full timeUTILIZATION REVIEW NURSE - PRN Baltimore, MD ...
-
UTILIZATION REVIEW NURSE
2 weeks ago
Baltimore, MD, United States LifeBridge Health Full timeUTILIZATION REVIEW NURSE - PRN Baltimore, MD ...
-
UTILIZATION REVIEW NURSE
2 weeks ago
Baltimore, MD, United States LifeBridge Health Full timeUTILIZATION REVIEW NURSE (RN) - PRN Baltimore, MD ...
-
UTILIZATION REVIEW NURSE
2 weeks ago
Baltimore, MD, United States LifeBridge Health Full timeUTILIZATION REVIEW NURSE (RN) - PRN Baltimore, MD ...
-
UTILIZATION REVIEW NURSE
2 weeks ago
Baltimore, MD, United States LifeBridge Health Full timeUTILIZATION REVIEW NURSE (RN) - PRN Baltimore, MD ...
-
Medical Records Nurse
2 weeks ago
Baltimore, MD, United States Fresenius Medical Care Full timePOSITION FEATURES: Paid one on one training and education provided Empower, engage and train dialysis patients on peritoneal and home hemodialysis using state of the art training programs and equipment Primarily works in the clinic setting and conducts initial home visits with another staff member present Position functions as an onsite...
-
Clinical Nurse Specialist
4 weeks ago
Baltimore, MD, United States University of Maryland Medical System Full timeJob Description Company Description Renowned as the academic flagship of the University of Maryland Medical System, our Magnet®-designated facility is a nationally recognized, academic medical center with opportunities across the continuum of care. Come join UMMC and discover the atmosphere where talents and ideas come together to enhance patient care and...
-
Clinical Nurse Specialist
4 weeks ago
Baltimore, MD, United States University of Maryland Medical System Full timeRenowned as the academic flagship of the University of Maryland Medical System, our Magnet®-designated facility is a nationally recognized, academic medical center with opportunities across the continuum of care. Come join UMMC and discover the atmosphere where talents and ideas come together to enhance patient care and advance the science of nursing....
-
Clinical Research Nurse
4 weeks ago
Baltimore, United States Spectrum Clinical Research Inc Full timeThe Clinical Research Nurse is an integral part of the study team. Using essential nursing skills, the Clinical Research Nurse leads the study staff in providing excellent patient care for research participants.ROLES AND RESPONSIBILITIES•Follows Good Clinical Practice guidelines to facilitate clinical trial protocols from site activation to study...
-
Baltimore, MD, United States Fresenius Medical Care Full timeThe registered professional nurse (CAP RN 1) position is an entry level designation into the Clinical Advancement Program for Registered Nurses. The CAP RN 1 is accountable and responsible for the provision and coordination of clinically competent care including assessment, planning, intervention and evaluation for an assigned group of patients. As a member...
-
Baltimore, MD, United States Fresenius Medical Care Full timeOutpatient Registered Nurse PURPOSE AND SCOPE: Functions as part of the hemodialysis health care team as a Staff Registered Nurse to ensure provision of quality patient care on a daily basis in accordance with FMS policies, procedures, and training. Supports the FMCNA's mission, vision, values, and customer service philosophy. Supports the FMCNA...
-
Ambulatory Clinical Manager
3 weeks ago
Baltimore, MD, United States Baltimore Medical System Full timeAgnes Family Health Center is seeking an experienced RN Health Center Clinical Manager who has a passion for community health medicine! Working in collaboration with the Center's Medical Director and Administrator, the Clinical Manager is responsible for health center clinical and dental operations, referral coordination and programs. The Clinical Manager...
-
Registered Nurse
2 weeks ago
Baltimore, MD, United States Mercy Medical Center Mary Catherine Bunting Center Full timeRegistered Nurse (RN) - Medical Surgical Flex Pool Summary Clinical Nurse (RN) -- Medical Surgical Flex Pool Mercy Medical Center, a Magnet-designated facility, with its rich history and visible dedication to serving the needs of the Baltimore community, is seeking an experienced RN to join the team in Mercy Medical Center's Med/Surg Flex Pool. Our...
-
RN - Medical Nursing - Full time
5 days ago
Baltimore, MD, United States Medical Solutions Full timeMedical Solutions is seeking a travel nurse RN Med Surg for a travel nursing job in Baltimore, Maryland. Shift: 12 hours, days ~ Employment Type: Travel We’re seeking talented healthcare professionals whose adventure game is as strong as their clinical game. Some of the industry-leading benefits enjoyed by Medical Solutions travel nurses and ...