Job Description:
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