Resp & Qualifications 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 and Govt Programs. 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. This role sits within the Forensic Nurse Team in Payment Integrity.
ESSENTIAL FUNCTIONS:- 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:Education Level: High School Diploma or GED.
Licenses/Certifications Upon Hire Required:- RN - Registered Nurse - State Licensure And/or Compact State Licensure RN-VA, DC and or MD.
Experience: 3 years acute clinical experience, previous case management, discharge planning or utilization review experience.
Preferred Qualifications:- Bachelor's degree in Nursing.
- Certified Coding Professional (Inpatient).
Knowledge, Skills and Abilities (KSAs)- Ability to effectively communicate and provide positive customer service to every internal and external customer.
- Strong interpersonal skills. Ability to work independently, as well as a member of a team.
- Current knowledge of clinical practices and related medical policies.
- Strong organizational skills, ability to prioritize responsibilities with attention to detail.
- Experience in using Microsoft Office (Excel, Word, Power Point, etc.) and web-based technology.
- Must possess excellent verbal and written communication skills.
- 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.
Salary Range: $67,320 - $133,705
Salary Range Disclaimer The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
PHYSICAL DEMANDS:The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
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