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Overview
Position: Clinical Medical Review Nurse – Contract
Pay Range: $35.57/hr - $40.57/hr
Responsibilities 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.
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.
Participates in medical policy meetings, nurses' forums, and review sessions with Medical and Dental directors, special projects and task forces/committees as assigned.
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 Ability to effectively communicate and provide positive customer service to every internal and external customer. Proficient in relevant areas.
Strong interpersonal skills. Ability to work independently, as well as a member of a team. Proficient.
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, PowerPoint, etc.) and web-based technology, proficient as well as electronic medical record retrieval.
Must possess excellent verbal and written communication skills. Advanced.
Licenses/Certifications LPN or RN - State Licensure And/or Compact State Licensure RN/LPN-VA, and/or MD Upon Hire Req.
Job Details Seniority level: Entry level
Employment type: Contract
Job function: Health Care Provider
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