Clinical Medical Review Nurse

Job Title: Clinical Medical Review Nurse

Location: Baltimore, MD

Type: Contract

Compensation: $41.50 per hour

Work Model: Hybrid – onsite and remote

Hours: 40.0 hours per week

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.

Requirements

• 3 years acute clinical experience, previous case management, discharge planning, or utilization review experience.

• Willingness to travel to provider locations to retrieve medical records upon business need.

• Bachelor's degree in Nursing.

• Ambulatory Practice Remote EMR Access.

• Ability to effectively communicate and provide positive customer service to internal and external customers.

• Strong interpersonal skills.

• Ability to work independently and as a team member.

• Current knowledge of clinical practices and related medical policies.

• Strong organizational skills, with the ability to prioritize responsibilities and attention to detail.

• Experience in using Microsoft Office (Excel, Word, PowerPoint, etc.) and web-based technology.

• Must possess excellent verbal and written communication skills.

• Licenses/Certifications: RN - Registered Nurse - State Licensure And/or Compact State Licensure RN-VA, DC, and MD upon hire; or LPN - Licensed Practical Nurse - State Licensure And/or Compact State Licensure LPN-VA, DC, and MD upon hire.

System One, and its subsidiaries including Joulé and Mountain Ltd., are leaders in delivering outsourced services and workforce solutions across North America. We help clients get work done more efficiently and economically, without compromising quality. System One not only serves as a valued partner for our clients, but we offer eligible employees health and welfare benefits coverage options including medical, dental, vision, spending accounts, life insurance, voluntary plans, as well as participation in a 401(k) plan.

System One is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, age, national origin, disability, family care or medical leave status, genetic information, veteran status, marital status, or any other characteristic protected by applicable federal, state, or local law.

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System One, and its subsidiaries including Joulé, ALTA IT Services, CM Access, TPGS, and MOUNTAIN, LTD., are leaders in delivering workforce solutions and integrated services across North America. We help clients get work done more efficiently and economically, without compromising quality. System One not only serves as a valued partner for our clients, but we offer eligible full-time employees health and welfare benefits coverage options including medical, dental, vision, spending accounts, life insurance, voluntary plans, as well as participation in a 401(k) plan.

System One is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, age, national origin, disability, family care or medical leave status, genetic information, veteran status, marital status, or any other characteristic protected by applicable federal, state, or local law.