RN Clinical Medical Review Nurse

Job Summary

Working remotely from the greater Baltimore metropolitan area, the full-time RN Clinical Medical Review Nurse will manage the review of professional and institutional claims, analyze medical information for enrollment eligibility, and support claims processing and adjudication.

Key responsibilities

• Receives, researches, reviews, and analyzes claims using nursing clinical judgment and corporate policies
• Provides pricing of procedure codes and interprets medical information utilizing CPT and HCPCS manuals
• Participates in medical policy meetings and collaborates with medical directors on special projects

Required qualifications

• Bachelor's degree in Nursing or equivalent work experience (4 years in lieu of a degree)
• Current RN state licensure or compact state licensure in VA, DC, or MD
• Minimum of 3 years of acute clinical experience, including case management or utilization review
• Experience in making clinical decisions related to pre-claim submissions and appeals
• Proficiency in Microsoft Office and web-based technology