Nurse, Clinical Medical Review

2 weeks ago

Baltimore, United States ICONMA Full time

Our Client, a Health Insurance company, is looking for a Nurse, Clinical Medical Review for their Baltimore, MA /Hybrid location.

Responsibilities:

  • 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.
  • 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.

Requirements:
  • Experience: 3 years acute clinical experience, previous case management, discharge planning or utilization review experience
  • 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
  • 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.
  • RN or LPN - Registered Nurse/Licensed Practical Nurse - State Licensure And/or Compact State Licensure RN-VA, DC and or MD Upon Hire Req
  • Electronic Medical Record Retrieval

Why Should You Apply?
  • Health Benefits
  • Referral Program
  • Excellent growth and advancement opportunities

As an equal opportunity employer, ICONMA provides an employment environment that supports and encourages the abilities of all persons without regard to race, color, religion, gender, sexual orientation, gender identity or express, ethnicity, national origin, age, disability status, political affiliation, genetics, marital status, protected veteran status, or any other characteristic protected by federal, state, or local laws.

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