Clinical Medical Review Nurse

1 day ago


Baltimore, Maryland, United States Zolon Tech Inc. Full time

Job Title: HEDIS/Clinical Medical Review Nurse

Job Summary:

Zolon Tech Inc. is seeking a skilled Clinical Medical Review Nurse to join our team. The successful candidate will be responsible for reviewing professional and institutional claims, as well as provider appeals, to determine eligibility for benefits and support claims processing and/or adjudication.

Key Responsibilities:

  • Conduct day-to-day review of medical claims and provider appeals to determine medical risk to the organization.
  • Assist in determining acceptable medical risk by analyzing medical information of applicants for enrollment in specific policies.
  • Collaborate with cross-functional teams to ensure accurate and timely claims processing and adjudication.
  • Stay up-to-date with industry developments and regulatory requirements to ensure compliance.

Requirements:

  • 3+ years of HEDIS experience is required.
  • LPN or RN is required.
  • Excellent analytical and problem-solving skills.
  • Ability to work in a fast-paced environment and meet deadlines.

Preferred Qualifications:

  • Knowledge of EPIC is a plus.
  • Experience with medical records review and analysis.


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