Clinical Medical Review Nurse

Location: Hybrid in Columbia, Maryland

What you will do

• Review and analyze professional and institutional claims using nursing judgment, medical policies, and critical-thinking skills.
• Evaluate provider appeals and perform pre- and post-claim medical reviews to support claims processing and adjudication.
• Research clinical topics and assess their impact on medical policies.
• Price procedures requiring individual consideration or classified as not otherwise classified in the CPT manual.
• Participate in medical policy meetings, nurses' forums, review sessions, special projects, and task forces.
• Perform medical underwriting and risk assessment by reviewing subscriber applications and medical records.

Requirements

• Active RN or LPN license issued in Maryland, Virginia, Washington, DC, or through Compact NLC licensure.
• Bachelor's degree, associate's degree, or diploma in Nursing.
• At least 3 years of clinical experience.
• Proficiency with Microsoft Office and Excel.
• Ability to navigate an electronic medical record system.

Nice to have

• HEDIS knowledge, including abstraction and over-read experience.
• Ambulatory care experience.
• Experience with Medicare and Medicaid measures.

Culture & Benefits

• Six-month contract engagement.
• Participation in professional forums, medical policy meetings, and cross-functional review sessions.